Theoryat aGlance A Guide For Health Promotion Practice

(Second Edition)

US DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

Foreword

A decade ago the first edition of Theory at a Glance was published The guide was a welcome resource for public health practitioners seeking a single concise summary of health behavior theories that was neither overwhelming nor superficial As a government publication in the public domain it also provided cash-strapped

health departments with access to a seminal integration of scholarly work that was useful to program staff interns and directors alike Although they were not the primary target audience members of the public health research community also utilized Theory at a Glance both as a quick desk reference and as a primer for their students

The National Cancer Institute is pleased to sponsor the publication of this guide but its relevance is by no means limited to cancer prevention and control The principles described herein can serve as frameworks for many domains of public health intervention complementing focused evidence reviews such as Centers for Disease Control and Preventionrsquos Guide to Community Preventive Services This report also complements a number of other efforts by NCI and our federal partners to facilitate more rigorous testing and application of health behavior theories through training workshops and the development of new Web-based resources

One reason theory is so useful is that it helps us articulate assumptions and hypotheses concerning our strategies and targets of intervention Debates among policymakers concerning public health programs are often complicated by unspoken assumptions or confusion about which data are relevant Theory can inform these debates by clarifying key constructs and their presumed relationships Especially when the evidence base is small advocates of one approach or another can be challenged to address the mechanisms by which a program is expected to have an impact By specifying these alternative pathways to change program evaluations can be designed to ensure that regardless of the outcome improvements in knowledge program design and implementation will occur

I am pleased to introduce this second edition of Theory at a Glance I am especially impressed that the lead authors Dr Barbara K Rimer and Dr Karen Glanz have enhanced and updated it throughout without diminishing the clarity and efficiency of the original We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice

Robert T Croyle PhD Director Division of Cancer Control and Population Sciences National Cancer Institute

Spring 2005

Acknowledgements

The National Cancer Institute would like to thank Barbara Rimer DrPH and Karen Glanz PhD MPH authors of the original monograph whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners Both have provided hours of review and consultation and we are grateful to them for their contributions

Thanks to the staffs of the Office of Communications particularly Margaret Farrell and the Division of Cancer Control and Population Sciences and Kelly Blake who guided this monograph to completion We appreciate in particular the work of Karen Harris whose attention to detail and commitment to excellence enhanced the monographrsquos content and quality

Tables and Figures Table of Contents

Introduction viii Audience and Purpose 1

Contents 1

Part 1 Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice 4

What Is Theory 4 How Can Theory Help Plan Effective Programs 4

Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5

Using Theory to Address Health Issues in Diverse Populations 7

Part 2 Theories and Applications 9 The Ecological Perspective A Multilevel Interactive Approach 10

Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12

Health Belief Model 13 Stages of Change Model 15

Theory of Planned Behavior 16 Precaution Adoption Process Model 18

Interpersonal Level 19 Social Cognitive Theory 19

Community Level 22 Community Organization and Other Participatory Models 23

Diffusion of Innovations 27 Communication Theory 29

Media Effects 30 Agenda Setting 30

New Communication Technologies 31

Part 3 Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36

PRECEDE-PROCEED 39 Where to Begin Choosing the Right Theories 43

A Few Final Words 44

Sources 48

References 49

Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10

Tables

An Ecological Perspective Levels of Influence 11 Health Belief Model 14

Stages of Change Model 15 Theory of Planned Behavior 17

Social Cognitive Theory 20 Community Organization 24

Concepts in Diffusion of Innovations 27 Key Attributes Affecting the Speed and Extent of an Innovationrsquos Diffusion 28

Agenda Setting Concepts Definitions and Applications 31 Diagnostic Elements of PRECEDE-PROCEED 42

Summary of Theories Focus and Key Concepts 45

Figures

Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 A Multilevel Approach to Epidemiology 10

Theory of Reasoned Action and Theory of Planned Behavior 18 Stages of the Precaution Adoption Process Model 19

An Integrative Model 21 Sociocultural Environment Logic Framework 26

An Asthma Self-Management Video Game for Children 33 Social Marketing Wheel 38

The PRECEDE-PROCEED Model 40 Using Theory to Plan Multilevel Interventions 46

viii

T H E O

R Y

AT

A G

L A N

C E

Introduction

T his monograph Theory at a Glance Application to Health Promotion and Health Behavior (Second Edition) describes influential theories of health-related behaviors processes of shaping behavior and the effects of community and environmental factors on behavior It complements existing resources that offer tools techniques

and model programs for practice such as Making Health Communication Programs Work A Plannerrsquos Guide i and the Web portal Cancer Control PLANET (Plan Link Act Network with Evidence-based Tools)ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs (For the purposes of this monograph health promotion is broadly defined as the process of enabling people to increase control over and to improve their health Thus the focus goes beyond traditional primary and secondary prevention programs)

For nearly a decade public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning implementation and evaluation We have received many testimonials about the First Editionrsquos usefulness and requests for additional copies This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations Theory at a Glance can be used as a stand-alone handbook as part of in-house staff development programs or in conjunction with theory texts and continuing education workshops

For easy reference the monograph includes only a small number of current and applicable health behavior theories The theories reviewed here are widely used for the purposes of cancer control defining risk and segmenting populations Much of the content for this publication has been adapted from the third edition of Glanz Rimer and Lewisrsquo Health Behavior and Health Education Theory Research and Practice 1 published by Jossey-Bass in San Francisco Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph

i Making Health Communication Programs Work (httpwwwncinihgovpinkbook) describes a practical approach for planning and implementing health communication efforts

ii Cancer Control PLANET (httpcancercontrolplanetcancergov) provides access to data and resources that can help planners program staff and researchers to design implement and evaluate evidence-based cancer control programs

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies community organizations health care settings schools and the private sector

Interventions based on health behavior theory are not guaranteed to succeed but they are much more likely to produce desired outcomes Theory at a Glance is designed to help users understand how individuals groups and organizations behave and changemdashknowledge they can use to design effective programs For information about specific evidence-based interventions to promote health and prevent disease readers may also wish to consult the Guide to Community Preventive Services published by the Centers for Disease Control and Prevention (CDC) at wwwthecommunityguideorg

Contents

This monograph consists of three parts For each theory the text highlights key concepts and their applications These summaries may be used as ldquochecklistsrdquo of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior

Part 1 Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behaviorhealth promotion practice and provides basic definitions

Part 2 Theories and Applications presents an ecological perspective on health behaviorhealth promotion programs It describes eight theories and models that explain individual interpersonal and community behavior and offers approaches to solving problems A brief description of each theory is followed by definitions of key concepts and examples or case studies The section also explores the use of new communication technologies

Part 3 Putting Theory and Practice Together explains how theory can be used in health behaviorhealth promotion program planning implementation and evaluation Two comprehensive planning models PRECEDE-PROCEED and social marketing are reviewed

1

INTRO

T H

E O R

Y AT A

G L A

N C

E

Foreword

A decade ago the first edition of Theory at a Glance was published The guide was a welcome resource for public health practitioners seeking a single concise summary of health behavior theories that was neither overwhelming nor superficial As a government publication in the public domain it also provided cash-strapped

health departments with access to a seminal integration of scholarly work that was useful to program staff interns and directors alike Although they were not the primary target audience members of the public health research community also utilized Theory at a Glance both as a quick desk reference and as a primer for their students

The National Cancer Institute is pleased to sponsor the publication of this guide but its relevance is by no means limited to cancer prevention and control The principles described herein can serve as frameworks for many domains of public health intervention complementing focused evidence reviews such as Centers for Disease Control and Preventionrsquos Guide to Community Preventive Services This report also complements a number of other efforts by NCI and our federal partners to facilitate more rigorous testing and application of health behavior theories through training workshops and the development of new Web-based resources

One reason theory is so useful is that it helps us articulate assumptions and hypotheses concerning our strategies and targets of intervention Debates among policymakers concerning public health programs are often complicated by unspoken assumptions or confusion about which data are relevant Theory can inform these debates by clarifying key constructs and their presumed relationships Especially when the evidence base is small advocates of one approach or another can be challenged to address the mechanisms by which a program is expected to have an impact By specifying these alternative pathways to change program evaluations can be designed to ensure that regardless of the outcome improvements in knowledge program design and implementation will occur

I am pleased to introduce this second edition of Theory at a Glance I am especially impressed that the lead authors Dr Barbara K Rimer and Dr Karen Glanz have enhanced and updated it throughout without diminishing the clarity and efficiency of the original We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice

Robert T Croyle PhD Director Division of Cancer Control and Population Sciences National Cancer Institute

Spring 2005

Acknowledgements

The National Cancer Institute would like to thank Barbara Rimer DrPH and Karen Glanz PhD MPH authors of the original monograph whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners Both have provided hours of review and consultation and we are grateful to them for their contributions

Thanks to the staffs of the Office of Communications particularly Margaret Farrell and the Division of Cancer Control and Population Sciences and Kelly Blake who guided this monograph to completion We appreciate in particular the work of Karen Harris whose attention to detail and commitment to excellence enhanced the monographrsquos content and quality

Tables and Figures Table of Contents

Introduction viii Audience and Purpose 1

Contents 1

Part 1 Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice 4

What Is Theory 4 How Can Theory Help Plan Effective Programs 4

Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5

Using Theory to Address Health Issues in Diverse Populations 7

Part 2 Theories and Applications 9 The Ecological Perspective A Multilevel Interactive Approach 10

Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12

Health Belief Model 13 Stages of Change Model 15

Theory of Planned Behavior 16 Precaution Adoption Process Model 18

Interpersonal Level 19 Social Cognitive Theory 19

Community Level 22 Community Organization and Other Participatory Models 23

Diffusion of Innovations 27 Communication Theory 29

Media Effects 30 Agenda Setting 30

New Communication Technologies 31

Part 3 Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36

PRECEDE-PROCEED 39 Where to Begin Choosing the Right Theories 43

A Few Final Words 44

Sources 48

References 49

Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10

Tables

An Ecological Perspective Levels of Influence 11 Health Belief Model 14

Stages of Change Model 15 Theory of Planned Behavior 17

Social Cognitive Theory 20 Community Organization 24

Concepts in Diffusion of Innovations 27 Key Attributes Affecting the Speed and Extent of an Innovationrsquos Diffusion 28

Agenda Setting Concepts Definitions and Applications 31 Diagnostic Elements of PRECEDE-PROCEED 42

Summary of Theories Focus and Key Concepts 45

Figures

Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 A Multilevel Approach to Epidemiology 10

Theory of Reasoned Action and Theory of Planned Behavior 18 Stages of the Precaution Adoption Process Model 19

An Integrative Model 21 Sociocultural Environment Logic Framework 26

An Asthma Self-Management Video Game for Children 33 Social Marketing Wheel 38

The PRECEDE-PROCEED Model 40 Using Theory to Plan Multilevel Interventions 46

viii

T H E O

R Y

AT

A G

L A N

C E

Introduction

T his monograph Theory at a Glance Application to Health Promotion and Health Behavior (Second Edition) describes influential theories of health-related behaviors processes of shaping behavior and the effects of community and environmental factors on behavior It complements existing resources that offer tools techniques

and model programs for practice such as Making Health Communication Programs Work A Plannerrsquos Guide i and the Web portal Cancer Control PLANET (Plan Link Act Network with Evidence-based Tools)ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs (For the purposes of this monograph health promotion is broadly defined as the process of enabling people to increase control over and to improve their health Thus the focus goes beyond traditional primary and secondary prevention programs)

For nearly a decade public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning implementation and evaluation We have received many testimonials about the First Editionrsquos usefulness and requests for additional copies This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations Theory at a Glance can be used as a stand-alone handbook as part of in-house staff development programs or in conjunction with theory texts and continuing education workshops

For easy reference the monograph includes only a small number of current and applicable health behavior theories The theories reviewed here are widely used for the purposes of cancer control defining risk and segmenting populations Much of the content for this publication has been adapted from the third edition of Glanz Rimer and Lewisrsquo Health Behavior and Health Education Theory Research and Practice 1 published by Jossey-Bass in San Francisco Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph

i Making Health Communication Programs Work (httpwwwncinihgovpinkbook) describes a practical approach for planning and implementing health communication efforts

ii Cancer Control PLANET (httpcancercontrolplanetcancergov) provides access to data and resources that can help planners program staff and researchers to design implement and evaluate evidence-based cancer control programs

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies community organizations health care settings schools and the private sector

Interventions based on health behavior theory are not guaranteed to succeed but they are much more likely to produce desired outcomes Theory at a Glance is designed to help users understand how individuals groups and organizations behave and changemdashknowledge they can use to design effective programs For information about specific evidence-based interventions to promote health and prevent disease readers may also wish to consult the Guide to Community Preventive Services published by the Centers for Disease Control and Prevention (CDC) at wwwthecommunityguideorg

Contents

This monograph consists of three parts For each theory the text highlights key concepts and their applications These summaries may be used as ldquochecklistsrdquo of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior

Part 1 Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behaviorhealth promotion practice and provides basic definitions

Part 2 Theories and Applications presents an ecological perspective on health behaviorhealth promotion programs It describes eight theories and models that explain individual interpersonal and community behavior and offers approaches to solving problems A brief description of each theory is followed by definitions of key concepts and examples or case studies The section also explores the use of new communication technologies

Part 3 Putting Theory and Practice Together explains how theory can be used in health behaviorhealth promotion program planning implementation and evaluation Two comprehensive planning models PRECEDE-PROCEED and social marketing are reviewed

1

INTRO

T H

E O R

Y AT A

G L A

N C

E

Acknowledgements

The National Cancer Institute would like to thank Barbara Rimer DrPH and Karen Glanz PhD MPH authors of the original monograph whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners Both have provided hours of review and consultation and we are grateful to them for their contributions

Thanks to the staffs of the Office of Communications particularly Margaret Farrell and the Division of Cancer Control and Population Sciences and Kelly Blake who guided this monograph to completion We appreciate in particular the work of Karen Harris whose attention to detail and commitment to excellence enhanced the monographrsquos content and quality

Tables and Figures Table of Contents

Introduction viii Audience and Purpose 1

Contents 1

Part 1 Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice 4

What Is Theory 4 How Can Theory Help Plan Effective Programs 4

Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5

Using Theory to Address Health Issues in Diverse Populations 7

Part 2 Theories and Applications 9 The Ecological Perspective A Multilevel Interactive Approach 10

Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12

Health Belief Model 13 Stages of Change Model 15

Theory of Planned Behavior 16 Precaution Adoption Process Model 18

Interpersonal Level 19 Social Cognitive Theory 19

Community Level 22 Community Organization and Other Participatory Models 23

Diffusion of Innovations 27 Communication Theory 29

Media Effects 30 Agenda Setting 30

New Communication Technologies 31

Part 3 Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36

PRECEDE-PROCEED 39 Where to Begin Choosing the Right Theories 43

A Few Final Words 44

Sources 48

References 49

Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10

Tables

An Ecological Perspective Levels of Influence 11 Health Belief Model 14

Stages of Change Model 15 Theory of Planned Behavior 17

Social Cognitive Theory 20 Community Organization 24

Concepts in Diffusion of Innovations 27 Key Attributes Affecting the Speed and Extent of an Innovationrsquos Diffusion 28

Agenda Setting Concepts Definitions and Applications 31 Diagnostic Elements of PRECEDE-PROCEED 42

Summary of Theories Focus and Key Concepts 45

Figures

Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 A Multilevel Approach to Epidemiology 10

Theory of Reasoned Action and Theory of Planned Behavior 18 Stages of the Precaution Adoption Process Model 19

An Integrative Model 21 Sociocultural Environment Logic Framework 26

An Asthma Self-Management Video Game for Children 33 Social Marketing Wheel 38

The PRECEDE-PROCEED Model 40 Using Theory to Plan Multilevel Interventions 46

viii

T H E O

R Y

AT

A G

L A N

C E

Introduction

T his monograph Theory at a Glance Application to Health Promotion and Health Behavior (Second Edition) describes influential theories of health-related behaviors processes of shaping behavior and the effects of community and environmental factors on behavior It complements existing resources that offer tools techniques

and model programs for practice such as Making Health Communication Programs Work A Plannerrsquos Guide i and the Web portal Cancer Control PLANET (Plan Link Act Network with Evidence-based Tools)ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs (For the purposes of this monograph health promotion is broadly defined as the process of enabling people to increase control over and to improve their health Thus the focus goes beyond traditional primary and secondary prevention programs)

For nearly a decade public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning implementation and evaluation We have received many testimonials about the First Editionrsquos usefulness and requests for additional copies This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations Theory at a Glance can be used as a stand-alone handbook as part of in-house staff development programs or in conjunction with theory texts and continuing education workshops

For easy reference the monograph includes only a small number of current and applicable health behavior theories The theories reviewed here are widely used for the purposes of cancer control defining risk and segmenting populations Much of the content for this publication has been adapted from the third edition of Glanz Rimer and Lewisrsquo Health Behavior and Health Education Theory Research and Practice 1 published by Jossey-Bass in San Francisco Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph

i Making Health Communication Programs Work (httpwwwncinihgovpinkbook) describes a practical approach for planning and implementing health communication efforts

ii Cancer Control PLANET (httpcancercontrolplanetcancergov) provides access to data and resources that can help planners program staff and researchers to design implement and evaluate evidence-based cancer control programs

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies community organizations health care settings schools and the private sector

Interventions based on health behavior theory are not guaranteed to succeed but they are much more likely to produce desired outcomes Theory at a Glance is designed to help users understand how individuals groups and organizations behave and changemdashknowledge they can use to design effective programs For information about specific evidence-based interventions to promote health and prevent disease readers may also wish to consult the Guide to Community Preventive Services published by the Centers for Disease Control and Prevention (CDC) at wwwthecommunityguideorg

Contents

This monograph consists of three parts For each theory the text highlights key concepts and their applications These summaries may be used as ldquochecklistsrdquo of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior

Part 1 Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behaviorhealth promotion practice and provides basic definitions

Part 2 Theories and Applications presents an ecological perspective on health behaviorhealth promotion programs It describes eight theories and models that explain individual interpersonal and community behavior and offers approaches to solving problems A brief description of each theory is followed by definitions of key concepts and examples or case studies The section also explores the use of new communication technologies

Part 3 Putting Theory and Practice Together explains how theory can be used in health behaviorhealth promotion program planning implementation and evaluation Two comprehensive planning models PRECEDE-PROCEED and social marketing are reviewed

1

INTRO

T H

E O R

Y AT A

G L A

N C

E

Tables and Figures Table of Contents

Introduction viii Audience and Purpose 1

Contents 1

Part 1 Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice 4

What Is Theory 4 How Can Theory Help Plan Effective Programs 4

Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5

Using Theory to Address Health Issues in Diverse Populations 7

Part 2 Theories and Applications 9 The Ecological Perspective A Multilevel Interactive Approach 10

Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12

Health Belief Model 13 Stages of Change Model 15

Theory of Planned Behavior 16 Precaution Adoption Process Model 18

Interpersonal Level 19 Social Cognitive Theory 19

Community Level 22 Community Organization and Other Participatory Models 23

Diffusion of Innovations 27 Communication Theory 29

Media Effects 30 Agenda Setting 30

New Communication Technologies 31

Part 3 Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36

PRECEDE-PROCEED 39 Where to Begin Choosing the Right Theories 43

A Few Final Words 44

Sources 48

References 49

Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10

Tables

An Ecological Perspective Levels of Influence 11 Health Belief Model 14

Stages of Change Model 15 Theory of Planned Behavior 17

Social Cognitive Theory 20 Community Organization 24

Concepts in Diffusion of Innovations 27 Key Attributes Affecting the Speed and Extent of an Innovationrsquos Diffusion 28

Agenda Setting Concepts Definitions and Applications 31 Diagnostic Elements of PRECEDE-PROCEED 42

Summary of Theories Focus and Key Concepts 45

Figures

Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 A Multilevel Approach to Epidemiology 10

Theory of Reasoned Action and Theory of Planned Behavior 18 Stages of the Precaution Adoption Process Model 19

An Integrative Model 21 Sociocultural Environment Logic Framework 26

An Asthma Self-Management Video Game for Children 33 Social Marketing Wheel 38

The PRECEDE-PROCEED Model 40 Using Theory to Plan Multilevel Interventions 46

viii

T H E O

R Y

AT

A G

L A N

C E

Introduction

T his monograph Theory at a Glance Application to Health Promotion and Health Behavior (Second Edition) describes influential theories of health-related behaviors processes of shaping behavior and the effects of community and environmental factors on behavior It complements existing resources that offer tools techniques

and model programs for practice such as Making Health Communication Programs Work A Plannerrsquos Guide i and the Web portal Cancer Control PLANET (Plan Link Act Network with Evidence-based Tools)ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs (For the purposes of this monograph health promotion is broadly defined as the process of enabling people to increase control over and to improve their health Thus the focus goes beyond traditional primary and secondary prevention programs)

For nearly a decade public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning implementation and evaluation We have received many testimonials about the First Editionrsquos usefulness and requests for additional copies This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations Theory at a Glance can be used as a stand-alone handbook as part of in-house staff development programs or in conjunction with theory texts and continuing education workshops

For easy reference the monograph includes only a small number of current and applicable health behavior theories The theories reviewed here are widely used for the purposes of cancer control defining risk and segmenting populations Much of the content for this publication has been adapted from the third edition of Glanz Rimer and Lewisrsquo Health Behavior and Health Education Theory Research and Practice 1 published by Jossey-Bass in San Francisco Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph

i Making Health Communication Programs Work (httpwwwncinihgovpinkbook) describes a practical approach for planning and implementing health communication efforts

ii Cancer Control PLANET (httpcancercontrolplanetcancergov) provides access to data and resources that can help planners program staff and researchers to design implement and evaluate evidence-based cancer control programs

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies community organizations health care settings schools and the private sector

Interventions based on health behavior theory are not guaranteed to succeed but they are much more likely to produce desired outcomes Theory at a Glance is designed to help users understand how individuals groups and organizations behave and changemdashknowledge they can use to design effective programs For information about specific evidence-based interventions to promote health and prevent disease readers may also wish to consult the Guide to Community Preventive Services published by the Centers for Disease Control and Prevention (CDC) at wwwthecommunityguideorg

Contents

This monograph consists of three parts For each theory the text highlights key concepts and their applications These summaries may be used as ldquochecklistsrdquo of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior

Part 1 Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behaviorhealth promotion practice and provides basic definitions

Part 2 Theories and Applications presents an ecological perspective on health behaviorhealth promotion programs It describes eight theories and models that explain individual interpersonal and community behavior and offers approaches to solving problems A brief description of each theory is followed by definitions of key concepts and examples or case studies The section also explores the use of new communication technologies

Part 3 Putting Theory and Practice Together explains how theory can be used in health behaviorhealth promotion program planning implementation and evaluation Two comprehensive planning models PRECEDE-PROCEED and social marketing are reviewed

1

INTRO

T H

E O R

Y AT A

G L A

N C

E

viii

T H E O

R Y

AT

A G

L A N

C E

Introduction

T his monograph Theory at a Glance Application to Health Promotion and Health Behavior (Second Edition) describes influential theories of health-related behaviors processes of shaping behavior and the effects of community and environmental factors on behavior It complements existing resources that offer tools techniques

and model programs for practice such as Making Health Communication Programs Work A Plannerrsquos Guide i and the Web portal Cancer Control PLANET (Plan Link Act Network with Evidence-based Tools)ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs (For the purposes of this monograph health promotion is broadly defined as the process of enabling people to increase control over and to improve their health Thus the focus goes beyond traditional primary and secondary prevention programs)

For nearly a decade public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning implementation and evaluation We have received many testimonials about the First Editionrsquos usefulness and requests for additional copies This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations Theory at a Glance can be used as a stand-alone handbook as part of in-house staff development programs or in conjunction with theory texts and continuing education workshops

For easy reference the monograph includes only a small number of current and applicable health behavior theories The theories reviewed here are widely used for the purposes of cancer control defining risk and segmenting populations Much of the content for this publication has been adapted from the third edition of Glanz Rimer and Lewisrsquo Health Behavior and Health Education Theory Research and Practice 1 published by Jossey-Bass in San Francisco Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph

i Making Health Communication Programs Work (httpwwwncinihgovpinkbook) describes a practical approach for planning and implementing health communication efforts

ii Cancer Control PLANET (httpcancercontrolplanetcancergov) provides access to data and resources that can help planners program staff and researchers to design implement and evaluate evidence-based cancer control programs

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies community organizations health care settings schools and the private sector

Interventions based on health behavior theory are not guaranteed to succeed but they are much more likely to produce desired outcomes Theory at a Glance is designed to help users understand how individuals groups and organizations behave and changemdashknowledge they can use to design effective programs For information about specific evidence-based interventions to promote health and prevent disease readers may also wish to consult the Guide to Community Preventive Services published by the Centers for Disease Control and Prevention (CDC) at wwwthecommunityguideorg

Contents

This monograph consists of three parts For each theory the text highlights key concepts and their applications These summaries may be used as ldquochecklistsrdquo of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior

Part 1 Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behaviorhealth promotion practice and provides basic definitions

Part 2 Theories and Applications presents an ecological perspective on health behaviorhealth promotion programs It describes eight theories and models that explain individual interpersonal and community behavior and offers approaches to solving problems A brief description of each theory is followed by definitions of key concepts and examples or case studies The section also explores the use of new communication technologies

Part 3 Putting Theory and Practice Together explains how theory can be used in health behaviorhealth promotion program planning implementation and evaluation Two comprehensive planning models PRECEDE-PROCEED and social marketing are reviewed

1

INTRO

T H

E O R

Y AT A

G L A

N C

E

Foundations of Theory in Health Promotion and Health BehaviorPart 1

3

PART 1

T H E O

R Y A

T A G

L A N

C E

4

T H E O

R Y

AT

A G

L A N

C E

Why Is Theory Important to Health Promotion and Health Behavior Practice

Effective public health health promotion and chronic disease management programs help people maintain and improve health reduce disease risks and manage chronic illness They can improve the well-being and self-sufficiency of individuals families organizations and communities Usually such successes require behavior change at many levels (eg individual organizational and community)

Not all health programs and initiatives are equally successful however Those most likely to achieve desired outcomes are based on a clear understanding of targeted health behaviors and the environmental context in which they occur Practitioners use strategic planning models to develop and manage these programs and continually improve them through meaningful evaluation Health behavior theory can play a critical role throughout the program planning process

What Is Theory

A theory presents a systematic way of understanding events or situations It is a set of concepts definitions and propositions that explain or predict these events or situations by illustrating the relationships between variables Theories must be applicable to a broad variety of situations They are by nature abstract and donrsquot have a specified content or topic area Like empty coffee cups theories have shapes and boundaries but nothing inside They become useful when filled with practical topics goals and problems

bull Concepts are the building blocksmdashthe primary elementsmdashof a theory

bull Constructs are concepts developed or adopted for use in a particular theory The key concepts of a given theory are its constructs

bull Variables are the operational forms of constructs They define the way a construct is to be measured in a specific situation Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program

bull Models may draw on a number of theories to help understand a particular problem in a certain setting or context They are not always as specified as theory

Most health behavior and health promotion theories were adapted from the social and behavioral sciences but applying them to health issues often requires that one be familiar with epidemiology and the biological sciences Health behavior and health promotion theories draw upon various disciplines such as psychology sociology anthropology consumer behavior and marketing Many are not highly developed or have not been rigorously tested Because of this they often are called conceptual frameworks or theoretical frameworks here the terms are used interchangeably

How Can Theory Help Plan Effective Programs

Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior It helps them to step back and consider the larger picture Like an artist a program planner who grounds health

interventions in theory creates innovative ways to address specific circumstances He or she does not depend on a ldquopaint-byshynumbersrdquo approach re-hashing stale ideas but uses a palette of behavior theories skillfully applying them to develop unique tailored solutions to problems

Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence-based interventions in public health behavioral medicine and medicine Theory provides a road map for studying problems developing appropriate interventions and evaluating their successes It can inform the plannerrsquos thinking during all of these stages offering insights that translate into stronger programs Theory can also help to explain the dynamics of health behaviors including processes for changing them and the influences of the many forces that affect health behaviors including social and physical environments Theory can also help planners identify the most suitable target audiences methods for fostering change and outcomes for evaluation

Researchers and practitioners use theory to investigate answers to the questions of ldquowhyrdquo ldquowhatrdquo and ldquohowrdquo health problems should be addressed By seeking answers to these questions they clarify the nature of targeted health behaviors That is theory guides the search for reasons why people do or do not engage in certain health behaviors it helps pinpoint what planners need to know before they develop public health programs and it suggests how to devise program strategies that reach target audiences and have an impact Theory also helps to identify which indicators should be monitored and measured during program evaluation For these reasons program planning implementation and monitoring processes based in theory are more likely

to succeed than those developed without the benefit of a theoretical perspective

Explanatory Theory and Change Theory

Explanatory theory describes the reasons why a problem exists It guides the search for factors that contribute to a problem (eg a lack of knowledge self-efficacy social support or resources) and can be changed Examples of explanatory theories include the Health Belief Model the Theory of Planned Behavior and the Precaution Adoption Process Model

Change theory guides the development of health interventions It spells out concepts that can be translated into program messages and strategies and offers a basis for program evaluation Change theory helps program planners to be explicit about their assumptions for why a program will work Examples of change theories include Community Organization and Diffusion of Innovations Figure 1 illustrates how explanatory theory and change theory can be used to plan and evaluate programs

Fitting Theory to the Field of Practice

This monograph includes descriptions and applications of some theories that are central to health behavior and health promotion practice today No single theory dominates health education and promotion nor should it the problems behaviors populations cultures and contexts of public health practice are broad and varied Some theories focus on individuals as the unit of change Others examine change within families institutions communities or cultures Adequately addressing an issue may require more than one theory and no one theory is suitable for all cases

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Fig

Explanatory Theory

Why What can

be changed

ure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs

Evaluation

ChangeTheory Problem Behavior Which strategies

Which messages or Assumptions about

Situation how a program should work

Planning

A Good Fit Characteristics of a Useful Theory

A useful theory makes assumptions about a behavior health problem target population or environment that are

bull Logical

bull Consistent with everyday observations bull Similar to those used in previous

successful programs and bull Supported by past research in the same

area or related ideas

Using Theory to Address Health Issues in Diverse Populations

The US population is growing more culturally and ethnically diverse An increasing body of research shows health disparities exist among various ethnic and socio-economic groups These findings highlight the importance of understanding

Because the social context in which behavior occurs is always evolving theories that were important in public health education a generation ago may be of limited use today At the same time new social science research allows theorists to refine and adapt existing theories A recent Institute of Medicine report2 observed that several theorists have converged in their views identifying several variables as central to behavior change As a result some constructs such as self-efficacy are central to multiple theories

Effective practice depends on using theories and strategies that are appropriate to a situation

One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model ldquofitsrdquo a particular issue A working knowledge of specific theories and familiarity with how

they have been applied in the past improves skills in this area Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process

Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (eg the most familiar theory the theory mentioned in a recent journal article etc) Instead this process starts with a thorough assessment of the situation the units of analysis or change the topic and the type of behavior to be addressed Because different theoretical frameworks are appropriate and practical for different situations selecting a theory that ldquofitsrdquo should be a careful deliberate process Start with the steps in the box at the top of the next page

the cultural backgrounds and life experiences of community members though research has not yet established when and under what circumstances targeted or tailored health communications are more effective than generic ones (Targeting involves using information about shared characteristics of a population subgroup to create a single intervention approach for that group In contrast tailoring is a process that uses an assessment to derive information about one specific person and then offers change or information strategies for an outcome of interest based on that personrsquos unique characteristics)3

Most health behavior theories can be applied to diverse cultural and ethnic groups but health practitioners must understand the characteristics of target populations (eg ethnicity socioeconomic status gender age and geographical location) to use these theories correctly

There are several reasons why culture and ethnicity are critical to consider when applying theory to a health problem First morbidity and mortality rates for different diseases vary by race and ethnicity second there are differences in the prevalence of risk behaviors among these groups and third the determinants of health behaviors vary across racial and ethnic groups

What People in the Field Say About Theory

ldquoTheory is different from most of the tools I use in my work Itrsquos more abstract but that can be a plus too A solid grounding in a handful of theories goes a long way toward helping me think through why I approach a health problem the way I dordquo

mdash County Health Educator

ldquoI used to think theory was just for students and researchers But now I have a better grasp of it I appreciate how practical it can berdquo

mdash State Chronic Disease Administrator

ldquoBy translating concepts from theory into real-world terms I can get my staff and community volunteers to take a closer look at why wersquore conducting programs the way we do and how they can succeed or failrdquo

mdash City Tobacco Control Coordinator

ldquoA good grasp of theory is essential for leadership It gives you a broader way of viewing your work And it helps create a vision for the future But of course itrsquos only worthwhile if I can translate it clearly and simply to my co-workersrdquo

mdash Regional Health Promotion Chief

ldquoItrsquos not as hard as I thought it would be to keep up with current theories More than ever these days there are tools and workshops to update us oftenrdquo

mdash Patient Education Coordinator

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Part 2 Theories and Applications 9

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The Ecological Perspective A interactions with their physical and socioshycultural environments Two key concepts Multilevel Interactive Approach of the ecological perspective help to identify intervention points for promoting healthContemporary health promotion involves first behavior both affects and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior such as knowledge attitudes beliefs and personality traits

Interpersonal Level Interpersonal processes and primary groups including family friends and peers that provide social identity support and role definition

Community Level Institutional Factors Rules regulations policies and informal structures which

may constrain or promote recommended behaviors

Community Factors Social networks and norms or standards which exist as formal or informal among individuals groups and organizations

Public Policy Local state and federal policies and laws that regulate or support healthy actions and practices for disease prevention early detection control and management

by multiple levels of influence second

Table 1 An Ecological Perspective Levels of Influence

more than simply educating individuals about healthy practices It includes efforts

individual behavior both shapes and isto change organizational behavior as well

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shaped by the social environment as the physical and social environment of communities It is also about developing and (reciprocal causation)

advocating for policies that support health such as economic incentives Health promotion programs that seek to address health problems across this spectrum employ a range of strategies and operate on multiple levels

The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem It highlights peoplersquos

To explain the first key concept of the ecological perspective multiple levels of influence McLeroy and colleagues (1988)4

identified five levels of influence for health-related behaviors and conditions Defined in Table 1 these levels include (1) intrapersonal or individual factors (2) interpersonal factors (3) institutional or organizational factors (4) community factors and (5) public policy factors

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Figure 2 A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

IndividualPopulation Health

GeneticConstitutional Factors

Environment

Life

cour

se

In practice addressing the community level requires taking into consideration institutional and public policy factors as well as social networks and norms Figure 2 illustrates how different levels of influence combine to affect population health

Each level of influence can affect health behavior For example suppose a woman delays getting a recommended mammogram (screening for breast cancer) At the individual level her inaction may be due to fears of finding out she has cancer

At the interpersonal level her doctor may neglect to tell her that she should get the test or she may have friends who say they do not believe it is important to get a mammogram At the organizational level it may be hard to schedule an appointment because there is only a part-time radiologist at the clinic At the policy level she may lack insurance coverage and thus be

unable to afford the fee Thus the outcome the womanrsquos failure to get a mammogram may result from multiple factors

The second key concept of an ecological perspective reciprocal causation suggests that people both influence and are influenced by those around them For example a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesnrsquot offer healthy food choices To comply with his doctorrsquos instructions he can try to change the environment by asking the cafeteria manager to add healthy items to the menu or he can dine elsewhere If he and enough of his fellow employees decide to find someplace else to eat the cafeteria may change its menu to maintain lunch business Thus the cafeteria environment may compel this man to change his dining habits but his new habits may ultimately bring about change in the cafeteria as well

Source Smedley BD Syme SL (eds) Institute of Medicine Promoting Health Strategies from Social and Behavioral Research Washington DC National Academies Press 2000

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

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Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

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According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

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Why Is Theory Important to Health Promotion and Health Behavior Practice

Effective public health health promotion and chronic disease management programs help people maintain and improve health reduce disease risks and manage chronic illness They can improve the well-being and self-sufficiency of individuals families organizations and communities Usually such successes require behavior change at many levels (eg individual organizational and community)

Not all health programs and initiatives are equally successful however Those most likely to achieve desired outcomes are based on a clear understanding of targeted health behaviors and the environmental context in which they occur Practitioners use strategic planning models to develop and manage these programs and continually improve them through meaningful evaluation Health behavior theory can play a critical role throughout the program planning process

What Is Theory

A theory presents a systematic way of understanding events or situations It is a set of concepts definitions and propositions that explain or predict these events or situations by illustrating the relationships between variables Theories must be applicable to a broad variety of situations They are by nature abstract and donrsquot have a specified content or topic area Like empty coffee cups theories have shapes and boundaries but nothing inside They become useful when filled with practical topics goals and problems

bull Concepts are the building blocksmdashthe primary elementsmdashof a theory

bull Constructs are concepts developed or adopted for use in a particular theory The key concepts of a given theory are its constructs

bull Variables are the operational forms of constructs They define the way a construct is to be measured in a specific situation Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program

bull Models may draw on a number of theories to help understand a particular problem in a certain setting or context They are not always as specified as theory

Most health behavior and health promotion theories were adapted from the social and behavioral sciences but applying them to health issues often requires that one be familiar with epidemiology and the biological sciences Health behavior and health promotion theories draw upon various disciplines such as psychology sociology anthropology consumer behavior and marketing Many are not highly developed or have not been rigorously tested Because of this they often are called conceptual frameworks or theoretical frameworks here the terms are used interchangeably

How Can Theory Help Plan Effective Programs

Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior It helps them to step back and consider the larger picture Like an artist a program planner who grounds health

interventions in theory creates innovative ways to address specific circumstances He or she does not depend on a ldquopaint-byshynumbersrdquo approach re-hashing stale ideas but uses a palette of behavior theories skillfully applying them to develop unique tailored solutions to problems

Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence-based interventions in public health behavioral medicine and medicine Theory provides a road map for studying problems developing appropriate interventions and evaluating their successes It can inform the plannerrsquos thinking during all of these stages offering insights that translate into stronger programs Theory can also help to explain the dynamics of health behaviors including processes for changing them and the influences of the many forces that affect health behaviors including social and physical environments Theory can also help planners identify the most suitable target audiences methods for fostering change and outcomes for evaluation

Researchers and practitioners use theory to investigate answers to the questions of ldquowhyrdquo ldquowhatrdquo and ldquohowrdquo health problems should be addressed By seeking answers to these questions they clarify the nature of targeted health behaviors That is theory guides the search for reasons why people do or do not engage in certain health behaviors it helps pinpoint what planners need to know before they develop public health programs and it suggests how to devise program strategies that reach target audiences and have an impact Theory also helps to identify which indicators should be monitored and measured during program evaluation For these reasons program planning implementation and monitoring processes based in theory are more likely

to succeed than those developed without the benefit of a theoretical perspective

Explanatory Theory and Change Theory

Explanatory theory describes the reasons why a problem exists It guides the search for factors that contribute to a problem (eg a lack of knowledge self-efficacy social support or resources) and can be changed Examples of explanatory theories include the Health Belief Model the Theory of Planned Behavior and the Precaution Adoption Process Model

Change theory guides the development of health interventions It spells out concepts that can be translated into program messages and strategies and offers a basis for program evaluation Change theory helps program planners to be explicit about their assumptions for why a program will work Examples of change theories include Community Organization and Diffusion of Innovations Figure 1 illustrates how explanatory theory and change theory can be used to plan and evaluate programs

Fitting Theory to the Field of Practice

This monograph includes descriptions and applications of some theories that are central to health behavior and health promotion practice today No single theory dominates health education and promotion nor should it the problems behaviors populations cultures and contexts of public health practice are broad and varied Some theories focus on individuals as the unit of change Others examine change within families institutions communities or cultures Adequately addressing an issue may require more than one theory and no one theory is suitable for all cases

5

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Fig

Explanatory Theory

Why What can

be changed

ure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs

Evaluation

ChangeTheory Problem Behavior Which strategies

Which messages or Assumptions about

Situation how a program should work

Planning

A Good Fit Characteristics of a Useful Theory

A useful theory makes assumptions about a behavior health problem target population or environment that are

bull Logical

bull Consistent with everyday observations bull Similar to those used in previous

successful programs and bull Supported by past research in the same

area or related ideas

Using Theory to Address Health Issues in Diverse Populations

The US population is growing more culturally and ethnically diverse An increasing body of research shows health disparities exist among various ethnic and socio-economic groups These findings highlight the importance of understanding

Because the social context in which behavior occurs is always evolving theories that were important in public health education a generation ago may be of limited use today At the same time new social science research allows theorists to refine and adapt existing theories A recent Institute of Medicine report2 observed that several theorists have converged in their views identifying several variables as central to behavior change As a result some constructs such as self-efficacy are central to multiple theories

Effective practice depends on using theories and strategies that are appropriate to a situation

One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model ldquofitsrdquo a particular issue A working knowledge of specific theories and familiarity with how

they have been applied in the past improves skills in this area Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process

Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (eg the most familiar theory the theory mentioned in a recent journal article etc) Instead this process starts with a thorough assessment of the situation the units of analysis or change the topic and the type of behavior to be addressed Because different theoretical frameworks are appropriate and practical for different situations selecting a theory that ldquofitsrdquo should be a careful deliberate process Start with the steps in the box at the top of the next page

the cultural backgrounds and life experiences of community members though research has not yet established when and under what circumstances targeted or tailored health communications are more effective than generic ones (Targeting involves using information about shared characteristics of a population subgroup to create a single intervention approach for that group In contrast tailoring is a process that uses an assessment to derive information about one specific person and then offers change or information strategies for an outcome of interest based on that personrsquos unique characteristics)3

Most health behavior theories can be applied to diverse cultural and ethnic groups but health practitioners must understand the characteristics of target populations (eg ethnicity socioeconomic status gender age and geographical location) to use these theories correctly

There are several reasons why culture and ethnicity are critical to consider when applying theory to a health problem First morbidity and mortality rates for different diseases vary by race and ethnicity second there are differences in the prevalence of risk behaviors among these groups and third the determinants of health behaviors vary across racial and ethnic groups

What People in the Field Say About Theory

ldquoTheory is different from most of the tools I use in my work Itrsquos more abstract but that can be a plus too A solid grounding in a handful of theories goes a long way toward helping me think through why I approach a health problem the way I dordquo

mdash County Health Educator

ldquoI used to think theory was just for students and researchers But now I have a better grasp of it I appreciate how practical it can berdquo

mdash State Chronic Disease Administrator

ldquoBy translating concepts from theory into real-world terms I can get my staff and community volunteers to take a closer look at why wersquore conducting programs the way we do and how they can succeed or failrdquo

mdash City Tobacco Control Coordinator

ldquoA good grasp of theory is essential for leadership It gives you a broader way of viewing your work And it helps create a vision for the future But of course itrsquos only worthwhile if I can translate it clearly and simply to my co-workersrdquo

mdash Regional Health Promotion Chief

ldquoItrsquos not as hard as I thought it would be to keep up with current theories More than ever these days there are tools and workshops to update us oftenrdquo

mdash Patient Education Coordinator

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Part 2 Theories and Applications 9

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The Ecological Perspective A interactions with their physical and socioshycultural environments Two key concepts Multilevel Interactive Approach of the ecological perspective help to identify intervention points for promoting healthContemporary health promotion involves first behavior both affects and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior such as knowledge attitudes beliefs and personality traits

Interpersonal Level Interpersonal processes and primary groups including family friends and peers that provide social identity support and role definition

Community Level Institutional Factors Rules regulations policies and informal structures which

may constrain or promote recommended behaviors

Community Factors Social networks and norms or standards which exist as formal or informal among individuals groups and organizations

Public Policy Local state and federal policies and laws that regulate or support healthy actions and practices for disease prevention early detection control and management

by multiple levels of influence second

Table 1 An Ecological Perspective Levels of Influence

more than simply educating individuals about healthy practices It includes efforts

individual behavior both shapes and isto change organizational behavior as well

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shaped by the social environment as the physical and social environment of communities It is also about developing and (reciprocal causation)

advocating for policies that support health such as economic incentives Health promotion programs that seek to address health problems across this spectrum employ a range of strategies and operate on multiple levels

The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem It highlights peoplersquos

To explain the first key concept of the ecological perspective multiple levels of influence McLeroy and colleagues (1988)4

identified five levels of influence for health-related behaviors and conditions Defined in Table 1 these levels include (1) intrapersonal or individual factors (2) interpersonal factors (3) institutional or organizational factors (4) community factors and (5) public policy factors

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Figure 2 A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

IndividualPopulation Health

GeneticConstitutional Factors

Environment

Life

cour

se

In practice addressing the community level requires taking into consideration institutional and public policy factors as well as social networks and norms Figure 2 illustrates how different levels of influence combine to affect population health

Each level of influence can affect health behavior For example suppose a woman delays getting a recommended mammogram (screening for breast cancer) At the individual level her inaction may be due to fears of finding out she has cancer

At the interpersonal level her doctor may neglect to tell her that she should get the test or she may have friends who say they do not believe it is important to get a mammogram At the organizational level it may be hard to schedule an appointment because there is only a part-time radiologist at the clinic At the policy level she may lack insurance coverage and thus be

unable to afford the fee Thus the outcome the womanrsquos failure to get a mammogram may result from multiple factors

The second key concept of an ecological perspective reciprocal causation suggests that people both influence and are influenced by those around them For example a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesnrsquot offer healthy food choices To comply with his doctorrsquos instructions he can try to change the environment by asking the cafeteria manager to add healthy items to the menu or he can dine elsewhere If he and enough of his fellow employees decide to find someplace else to eat the cafeteria may change its menu to maintain lunch business Thus the cafeteria environment may compel this man to change his dining habits but his new habits may ultimately bring about change in the cafeteria as well

Source Smedley BD Syme SL (eds) Institute of Medicine Promoting Health Strategies from Social and Behavioral Research Washington DC National Academies Press 2000

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

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Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

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According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

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Fig

Explanatory Theory

Why What can

be changed

ure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs

Evaluation

ChangeTheory Problem Behavior Which strategies

Which messages or Assumptions about

Situation how a program should work

Planning

A Good Fit Characteristics of a Useful Theory

A useful theory makes assumptions about a behavior health problem target population or environment that are

bull Logical

bull Consistent with everyday observations bull Similar to those used in previous

successful programs and bull Supported by past research in the same

area or related ideas

Using Theory to Address Health Issues in Diverse Populations

The US population is growing more culturally and ethnically diverse An increasing body of research shows health disparities exist among various ethnic and socio-economic groups These findings highlight the importance of understanding

Because the social context in which behavior occurs is always evolving theories that were important in public health education a generation ago may be of limited use today At the same time new social science research allows theorists to refine and adapt existing theories A recent Institute of Medicine report2 observed that several theorists have converged in their views identifying several variables as central to behavior change As a result some constructs such as self-efficacy are central to multiple theories

Effective practice depends on using theories and strategies that are appropriate to a situation

One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model ldquofitsrdquo a particular issue A working knowledge of specific theories and familiarity with how

they have been applied in the past improves skills in this area Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process

Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (eg the most familiar theory the theory mentioned in a recent journal article etc) Instead this process starts with a thorough assessment of the situation the units of analysis or change the topic and the type of behavior to be addressed Because different theoretical frameworks are appropriate and practical for different situations selecting a theory that ldquofitsrdquo should be a careful deliberate process Start with the steps in the box at the top of the next page

the cultural backgrounds and life experiences of community members though research has not yet established when and under what circumstances targeted or tailored health communications are more effective than generic ones (Targeting involves using information about shared characteristics of a population subgroup to create a single intervention approach for that group In contrast tailoring is a process that uses an assessment to derive information about one specific person and then offers change or information strategies for an outcome of interest based on that personrsquos unique characteristics)3

Most health behavior theories can be applied to diverse cultural and ethnic groups but health practitioners must understand the characteristics of target populations (eg ethnicity socioeconomic status gender age and geographical location) to use these theories correctly

There are several reasons why culture and ethnicity are critical to consider when applying theory to a health problem First morbidity and mortality rates for different diseases vary by race and ethnicity second there are differences in the prevalence of risk behaviors among these groups and third the determinants of health behaviors vary across racial and ethnic groups

What People in the Field Say About Theory

ldquoTheory is different from most of the tools I use in my work Itrsquos more abstract but that can be a plus too A solid grounding in a handful of theories goes a long way toward helping me think through why I approach a health problem the way I dordquo

mdash County Health Educator

ldquoI used to think theory was just for students and researchers But now I have a better grasp of it I appreciate how practical it can berdquo

mdash State Chronic Disease Administrator

ldquoBy translating concepts from theory into real-world terms I can get my staff and community volunteers to take a closer look at why wersquore conducting programs the way we do and how they can succeed or failrdquo

mdash City Tobacco Control Coordinator

ldquoA good grasp of theory is essential for leadership It gives you a broader way of viewing your work And it helps create a vision for the future But of course itrsquos only worthwhile if I can translate it clearly and simply to my co-workersrdquo

mdash Regional Health Promotion Chief

ldquoItrsquos not as hard as I thought it would be to keep up with current theories More than ever these days there are tools and workshops to update us oftenrdquo

mdash Patient Education Coordinator

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Part 2 Theories and Applications 9

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The Ecological Perspective A interactions with their physical and socioshycultural environments Two key concepts Multilevel Interactive Approach of the ecological perspective help to identify intervention points for promoting healthContemporary health promotion involves first behavior both affects and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior such as knowledge attitudes beliefs and personality traits

Interpersonal Level Interpersonal processes and primary groups including family friends and peers that provide social identity support and role definition

Community Level Institutional Factors Rules regulations policies and informal structures which

may constrain or promote recommended behaviors

Community Factors Social networks and norms or standards which exist as formal or informal among individuals groups and organizations

Public Policy Local state and federal policies and laws that regulate or support healthy actions and practices for disease prevention early detection control and management

by multiple levels of influence second

Table 1 An Ecological Perspective Levels of Influence

more than simply educating individuals about healthy practices It includes efforts

individual behavior both shapes and isto change organizational behavior as well

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shaped by the social environment as the physical and social environment of communities It is also about developing and (reciprocal causation)

advocating for policies that support health such as economic incentives Health promotion programs that seek to address health problems across this spectrum employ a range of strategies and operate on multiple levels

The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem It highlights peoplersquos

To explain the first key concept of the ecological perspective multiple levels of influence McLeroy and colleagues (1988)4

identified five levels of influence for health-related behaviors and conditions Defined in Table 1 these levels include (1) intrapersonal or individual factors (2) interpersonal factors (3) institutional or organizational factors (4) community factors and (5) public policy factors

10

T H E O

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AT

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Figure 2 A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

IndividualPopulation Health

GeneticConstitutional Factors

Environment

Life

cour

se

In practice addressing the community level requires taking into consideration institutional and public policy factors as well as social networks and norms Figure 2 illustrates how different levels of influence combine to affect population health

Each level of influence can affect health behavior For example suppose a woman delays getting a recommended mammogram (screening for breast cancer) At the individual level her inaction may be due to fears of finding out she has cancer

At the interpersonal level her doctor may neglect to tell her that she should get the test or she may have friends who say they do not believe it is important to get a mammogram At the organizational level it may be hard to schedule an appointment because there is only a part-time radiologist at the clinic At the policy level she may lack insurance coverage and thus be

unable to afford the fee Thus the outcome the womanrsquos failure to get a mammogram may result from multiple factors

The second key concept of an ecological perspective reciprocal causation suggests that people both influence and are influenced by those around them For example a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesnrsquot offer healthy food choices To comply with his doctorrsquos instructions he can try to change the environment by asking the cafeteria manager to add healthy items to the menu or he can dine elsewhere If he and enough of his fellow employees decide to find someplace else to eat the cafeteria may change its menu to maintain lunch business Thus the cafeteria environment may compel this man to change his dining habits but his new habits may ultimately bring about change in the cafeteria as well

Source Smedley BD Syme SL (eds) Institute of Medicine Promoting Health Strategies from Social and Behavioral Research Washington DC National Academies Press 2000

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

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According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

21

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

Part 2 Theories and Applications 9

PART 2

T H E O

R Y A

T A G

L A N

C E

The Ecological Perspective A interactions with their physical and socioshycultural environments Two key concepts Multilevel Interactive Approach of the ecological perspective help to identify intervention points for promoting healthContemporary health promotion involves first behavior both affects and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior such as knowledge attitudes beliefs and personality traits

Interpersonal Level Interpersonal processes and primary groups including family friends and peers that provide social identity support and role definition

Community Level Institutional Factors Rules regulations policies and informal structures which

may constrain or promote recommended behaviors

Community Factors Social networks and norms or standards which exist as formal or informal among individuals groups and organizations

Public Policy Local state and federal policies and laws that regulate or support healthy actions and practices for disease prevention early detection control and management

by multiple levels of influence second

Table 1 An Ecological Perspective Levels of Influence

more than simply educating individuals about healthy practices It includes efforts

individual behavior both shapes and isto change organizational behavior as well

11

PART 2

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

shaped by the social environment as the physical and social environment of communities It is also about developing and (reciprocal causation)

advocating for policies that support health such as economic incentives Health promotion programs that seek to address health problems across this spectrum employ a range of strategies and operate on multiple levels

The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem It highlights peoplersquos

To explain the first key concept of the ecological perspective multiple levels of influence McLeroy and colleagues (1988)4

identified five levels of influence for health-related behaviors and conditions Defined in Table 1 these levels include (1) intrapersonal or individual factors (2) interpersonal factors (3) institutional or organizational factors (4) community factors and (5) public policy factors

10

T H E O

R Y

AT

A G

L A N

C E

Figure 2 A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

IndividualPopulation Health

GeneticConstitutional Factors

Environment

Life

cour

se

In practice addressing the community level requires taking into consideration institutional and public policy factors as well as social networks and norms Figure 2 illustrates how different levels of influence combine to affect population health

Each level of influence can affect health behavior For example suppose a woman delays getting a recommended mammogram (screening for breast cancer) At the individual level her inaction may be due to fears of finding out she has cancer

At the interpersonal level her doctor may neglect to tell her that she should get the test or she may have friends who say they do not believe it is important to get a mammogram At the organizational level it may be hard to schedule an appointment because there is only a part-time radiologist at the clinic At the policy level she may lack insurance coverage and thus be

unable to afford the fee Thus the outcome the womanrsquos failure to get a mammogram may result from multiple factors

The second key concept of an ecological perspective reciprocal causation suggests that people both influence and are influenced by those around them For example a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesnrsquot offer healthy food choices To comply with his doctorrsquos instructions he can try to change the environment by asking the cafeteria manager to add healthy items to the menu or he can dine elsewhere If he and enough of his fellow employees decide to find someplace else to eat the cafeteria may change its menu to maintain lunch business Thus the cafeteria environment may compel this man to change his dining habits but his new habits may ultimately bring about change in the cafeteria as well

Source Smedley BD Syme SL (eds) Institute of Medicine Promoting Health Strategies from Social and Behavioral Research Washington DC National Academies Press 2000

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

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Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

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According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

The Ecological Perspective A interactions with their physical and socioshycultural environments Two key concepts Multilevel Interactive Approach of the ecological perspective help to identify intervention points for promoting healthContemporary health promotion involves first behavior both affects and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior such as knowledge attitudes beliefs and personality traits

Interpersonal Level Interpersonal processes and primary groups including family friends and peers that provide social identity support and role definition

Community Level Institutional Factors Rules regulations policies and informal structures which

may constrain or promote recommended behaviors

Community Factors Social networks and norms or standards which exist as formal or informal among individuals groups and organizations

Public Policy Local state and federal policies and laws that regulate or support healthy actions and practices for disease prevention early detection control and management

by multiple levels of influence second

Table 1 An Ecological Perspective Levels of Influence

more than simply educating individuals about healthy practices It includes efforts

individual behavior both shapes and isto change organizational behavior as well

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shaped by the social environment as the physical and social environment of communities It is also about developing and (reciprocal causation)

advocating for policies that support health such as economic incentives Health promotion programs that seek to address health problems across this spectrum employ a range of strategies and operate on multiple levels

The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem It highlights peoplersquos

To explain the first key concept of the ecological perspective multiple levels of influence McLeroy and colleagues (1988)4

identified five levels of influence for health-related behaviors and conditions Defined in Table 1 these levels include (1) intrapersonal or individual factors (2) interpersonal factors (3) institutional or organizational factors (4) community factors and (5) public policy factors

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Figure 2 A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

IndividualPopulation Health

GeneticConstitutional Factors

Environment

Life

cour

se

In practice addressing the community level requires taking into consideration institutional and public policy factors as well as social networks and norms Figure 2 illustrates how different levels of influence combine to affect population health

Each level of influence can affect health behavior For example suppose a woman delays getting a recommended mammogram (screening for breast cancer) At the individual level her inaction may be due to fears of finding out she has cancer

At the interpersonal level her doctor may neglect to tell her that she should get the test or she may have friends who say they do not believe it is important to get a mammogram At the organizational level it may be hard to schedule an appointment because there is only a part-time radiologist at the clinic At the policy level she may lack insurance coverage and thus be

unable to afford the fee Thus the outcome the womanrsquos failure to get a mammogram may result from multiple factors

The second key concept of an ecological perspective reciprocal causation suggests that people both influence and are influenced by those around them For example a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesnrsquot offer healthy food choices To comply with his doctorrsquos instructions he can try to change the environment by asking the cafeteria manager to add healthy items to the menu or he can dine elsewhere If he and enough of his fellow employees decide to find someplace else to eat the cafeteria may change its menu to maintain lunch business Thus the cafeteria environment may compel this man to change his dining habits but his new habits may ultimately bring about change in the cafeteria as well

Source Smedley BD Syme SL (eds) Institute of Medicine Promoting Health Strategies from Social and Behavioral Research Washington DC National Academies Press 2000

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

13

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

15

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A G

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

17

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S

16

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

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According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

12

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components For instance effective tobacco control programs often use multiple strategies to discourage smoking5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced Health promotion programs are more effective when planners consider multiple levels of influence on health problems

Theoretical Explanations of Three Levels of Influence

The next three sections examine theories and their applications at the individual (intrapersonal) interpersonal and community levels of the ecological perspective At the individual and interpersonal levels contemporary theories of health behavior can be broadly categorized as ldquoCognitive-Behavioralrdquo Three key concepts cut across these theories

1 Behavior is mediated by cognitions that is what people know and think affects how they act

2 Knowledge is necessary for but not sufficient to produce most behavior changes

3 Perceptions motivations skills and the social environment are key influences on behavior

Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors They supplement educational approaches with efforts to change the social and physical environment to support positive behavior change

Individual or Intrapersonal Level

The individual level is the most basic one in health promotion practice so planners must be able to explain and influence the behavior of individuals Many health practitioners spend most of their work time in one-on-one activities such as counseling or patient education and individuals are often the primary target audience for health education materials Because individual behavior is the fundamental unit of group behavior individual-level behavior change theories often comprise broader-level models of group organizational community and national behavior Individuals participate in groups manage organizations elect and appoint leaders and legislate policy Thus achieving policy and institutional change requires influencing individuals

In addition to exploring behavior individual-level theories focus on intrapersonal factors (those existing or occurring within the individual self or mind) Intrapersonal factors include knowledge attitudes beliefs motivation self-concept developmental history past experience and skills Individual-level theories are presented below

bull The Health Belief Model (HBM) addresses the individualrsquos perceptions of the threat posed by a health problem (susceptibility severity) the benefits of avoiding the threat and factors influencing the decision to act (barriers cues to action and self-efficacy)

bull The Stages of Change (Transtheoretical) Model describes individualsrsquo motivation and readiness to change a behavior

bull The Theory of Planned Behavior (TPB) examines the relations between an individualrsquos beliefs attitudes intentions behavior and perceived control over that behavior

bull The Precaution Adoption Process Model (PAPM) names seven stages in an individualrsquos journey from awareness to action It begins with lack of awareness and advances through subsequent stages of becoming aware deciding whether or not to act acting and maintaining the behavior

Health Belief Model (HBM) The Health Belief Model (HBM) was one of the first theories of health behavior and remains one of the most widely recognized in the field It was developed in the 1950s by a group of US Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease For example the Public Health Service was sending mobile X-ray units out to neighborhoods to offer free chest X-rays (screening for tuberculosis) Despite the fact that this service was offered without charge in a variety of convenient locations the program was of limited success The question was ldquoWhyrdquo

To find an answer social psychologists examined what was encouraging or discouraging people from participating in the programs They theorized that peoplersquos beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their readiness to act

In ensuing years researchers expanded upon this theory eventually concluding that six main constructs influence peoplersquos decisions about whether to take action to prevent screen for and control illness They argued that people are ready to act if they

bull Believe they are susceptible to the condition (perceived susceptibility)

bull Believe the condition has serious consequences (perceived severity)

bull Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

bull Believe costs of taking action (perceived barriers) are outweighed by the benefits

bull Are exposed to factors that prompt action (eg a television ad or a reminder from onersquos physician to get a mammogram) (cue to action)

bull Are confident in their ability to successfully perform an action (self-efficacy)

Since health motivation is its central focus the HBM is a good fit for addressing problem behaviors that evoke health concerns (eg high-risk sexual behavior and the possibility of contracting HIV) Together the six constructs of the HBM provide a useful framework for designing both short-term and long-term behavior change strategies (See Table 2) When applying the HBM to planning health programs practitioners should ground their efforts in an understanding of how susceptible the target population feels to the health problem whether they believe it is serious and whether they believe action can reduce the threat at an acceptable cost Attempting to effect changes in these factors is rarely as simple as it may appear

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Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

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Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

17

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16

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Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

R I E S

A N

D A

P P

L I C A

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S

According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

21

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A G

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S

Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

Table 2 Health Belief Model Stages of Change (Transtheoretical) Model of change Nonetheless the manner in Developed by Prochaska and DiClemente6 which they pass through these stages may the Stages of Change Model evolved out vary depending on the type of behavior of studies comparing the experiences of change For example a person who is tryingConcept Definition Potential Change Strategies

Perceived Beliefs about the chances bull Define what populations(s) are at risk and susceptibility of getting a condition their levels of risk

bull Tailor risk information based on an individualrsquos characteristics or behaviors

bull Help the individual develop an accurate perception of his or her own risk

Perceived severity Beliefs about the bull Specify the consequences of a condition seriousness of a condition and recommended action and its consequences

Perceived benefits Beliefs about the bull Explain how where and when to take effectiveness of taking action and what the potential positive action to reduce risk or results will be seriousness

Perceived barriers Beliefs about the material bull Offer reassurance incentives and and psychological costs assistance correct misinformation of taking action

Cues to action Factors that activate bull Provide rdquohow tordquo information promote rdquoreadiness to changerdquo awareness and employ reminder systems

Self-efficacy Confidence in onersquos ability bull Provide training and guidance in to take action performing action

bull Use progressive goal setting bull Give verbal reinforcement bull Demonstrate desired behaviors

smokers who quit on their own with those of smokers receiving professional treatment The modelrsquos basic premise is that behavior change is a process not an event As a person attempts to change a behavior he or she moves through five stages precontemplation contemplation preparation action and maintenance (see Table 3) Definitions of the stages vary slightly depending on the behavior at issue People at different points along this continuum have different informational needs and benefit from interventions designed for their stage

Whether individuals use self-management methods or take part in professional programs they go through the same stages

Table 3 Stages of Change Model

to give up smoking may experience the stages differently than someone who is seeking to improve their dietary habits by eating more fruits and vegetables

The Stages of Change Model has been applied to a variety of individual behaviors as well as to organizational change The Model is circular not linear In other words people do not systematically progress from one stage to the next ultimately ldquograduatingrdquo from the behavior change process Instead they may enter the change process at any stage relapse to an earlier stage and begin the process once more They may cycle through this process repeatedly and the process can truncate at any point

15

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R I E S

A N

D A

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T I O N

S

14

T H E O

R Y

AT

A G

L A N

C E

Stage Definition Potential Change Strategies

Precontemplation Has no intention of taking action within the next six months

Increase awareness of need for change personalize information about risks and benefits

Contemplation Intends to take action in the next six months

Motivate encourage making specific plans

Preparation Intends to take action within the next thirty days and has taken some behavioral steps in this direction

Assist with developing and implementing concrete action plans help set gradual goals

Action Has changed behavior for less than six months

Assist with feedback problem solving social support and reinforcement

Maintenance Has changed behavior for more than six months

Assist with coping reminders finding alternatives avoiding slipsrelapses (as applicable)

High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke but who say they have not experienced any symptoms Because they donrsquot feel sick they may not follow instructions to take prescribed medicine or lose weight The HBM can be useful for developing strategies to deal with noncompliance in such situations

According to the HBM asymptomatic people may not follow a prescribed treatment regimen unless they accept that though they have no symptoms they do in fact have hypertension (perceived susceptibility) They must understand that hypertension can lead to heart attacks and strokes (perceived severity) Taking prescribed medication or following a recommended weight loss program will reduce the risks (perceived benefits) without negative side effects or excessive difficulty (perceived barriers) Print materials reminder letters or pill calendars might encourage people to consistently follow their doctorsrsquo recommendations (cues to action) For those who have in the past had a hard time losing weight or maintaining weight loss a behavioral contract might help establish achievable short-term goals to build confidence (self-efficacy)

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

17

PART 2

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

16

T H E O

R Y

AT

A G

L A N

C E

Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

21

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20

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R Y

AT

A G

L A N

C E

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) The health educator decides to offer group smoking cessation clinics to employees at various times and locations Several months pass however and only 50 of the smokers sign up for the clinics At this point the health educator faces a dilemma how can the 150 smokers who are not participating in the clinics be reached

The Stages of Change Model offers perspective on ways to approach this problem First the model can be employed to help understand and explain why they are not attending the clinics Second it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior and maintain that change By asking a few simple questions the health educator can assess what stages of contemplation potential program participants are in For example

bull Are you interested in trying to quit smoking (Pre-contemplation)

bull Are you thinking about quitting smoking soon (Contemplation)

bull Are you ready to plan how you will quit smoking (Preparation)

bull Are you in the process of trying to quit smoking (Action)

bull Are you trying to stay smoke-free (Maintenance)

The employeesrsquo responses will help to pinpoint where the participants are on the continuum of change and to tailor messages strategies and programs appropriate to their needs For example individuals who enjoy smoking are not interested in trying to quit and therefore will not attend a smoking cessation clinic for them a more appropriate intervention might include educational interventions designed to move them out of the ldquoprecontemplationrdquo stage and into ldquocontemplationrdquo (eg using carbon monoxide testing to demonstrate the effect of smoking on health) On the other hand individuals who are ready to plan how to quit smoking (the ldquopreparationrdquo stage) can be encouraged to do so and moved to the next stage ldquoactionrdquo

a particular behavior Azjen and Driver7 situations however Peoplersquos perceptions added this construct to account for about controllability may have an important situations in which peoplersquos behavior or influence on behavior behavioral intention is influenced by factors beyond their control They argued that people might try harder to perform a behavior if they feel they have a high degree of control over it (See Table 4) It has application beyond these limited

Table 4 Theory of Planned Behavior

Concept Definition Measurement Approach

Behavioral intention Perceived likelihood of performing behavior

Are you likely or unlikely to (perform the behavior)

Attitude Personal evaluation of the behavior Do you see (the behavior) as good neutral or bad

Subjective norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve ofdisapprove of (the behavior)

Perceived behavioral control

Belief that one has and can exercise control over performing the behavior

Do you believe (performing the behavior) is up to you or not up to you

17

PART 2

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

16

T H E O

R Y

AT

A G

L A N

C E

Theory of Planned Behavior (TPB) The Theory of Planned Behavior (TPB) and the associated Theory of Reasoned Action (TRA) explore the relationship between behavior and beliefs attitudes and intentions Both the TPB and the TRA assume behavioral intention is the most important determinant of behavior According to these models behavioral intention is influenced by a personrsquos attitude toward performing a behavior and by beliefs about whether individuals who are important

to the person approve or disapprove of the behavior (subjective norm) The TPB and TRA assume all other factors (eg culture the environment) operate through the modelsrsquo constructs and do not independently explain the likelihood that a person will behave a certain way

The TPB differs from the TRA in that it includes one additional construct perceived behavioral control this construct has to do with peoplersquos beliefs that they can control

Surveillance data show that young acculturated Hispanic women are more likely to get Pap tests than those who are older and less acculturated8 A health department decides to implement a cervical cancer screening program targeting older Hispanic women In planning the campaign practitioners want to conduct a survey to learn what beliefs attitudes and intentions in this population are associated with seeking a Pap test They design the survey to gauge when the women received their last Pap test (behavior) how likely they are to seek a Pap test (intention) attitudes about getting a Pap test (attitude) whether or not ldquomost people who are important to merdquo would want them to get a Pap test (subjective norm) and whether or not getting a Pap test is something that is ldquounder my controlrdquo (perceived behavioral control) The department will compare survey results with data about who has or has not received a Pap test to identify beliefs attitudes and intentions that predict seeking one

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

21

PART 2

20

T H E O

R Y

AT

A G

L A N

C E

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior Figure 4 Stages of the Precaution Adoption Process Model

E C

N

A

T

A G

L Y

AR

O

E

H Note Upper blue section shows the Theory

T

of Reasoned Action the entire figure

Behavioral beliefs

Evaluation of behavioral outcomes

Attitude toward behavior

Normative beliefs

Motivation to comply

Subjective norm

Control beliefs

Perceived power

Perceived behavioral control

Behavioral intention

Behavior

19

PART 2

Stage 1 Unaware of Issue

Stage 2 Unengaged

by Issue

Stage 3 Deciding

About Acting

Stage 5 Decided to Act

Stage 6 Acting

Stage 4 Decided

Not to Act

Stage 7 Maintenance

18

shows the Theory of Planned Behavior

Figure 3 shows the TPBrsquos explanation for how behavioral intention determines behavior and how attitude toward behavior subjective norm and perceived behavioral control influence behavioral intention According to the model attitudes toward behavior are shaped by beliefs about what is entailed in performing the behavior and outcomes of the behavior Beliefs about social standards and motivation to comply with those norms affect subjective norms The presence or lack of things that will make it easier or harder to perform the behavior affect perceived behavioral control Thus a causal chain of beliefs attitudes and intentions drives behavior

Precaution Adoption Process Model The Precaution Adoption Process Model (PAPM) specifies seven distinct stages in the journey from lack of awareness to adoption andor maintenance of a behavior It is a relatively new model that has been applied to an increasing number of health behaviors including osteoporosis prevention colorectal cancer screening mammography hepatitis B vaccination and home testing for radon gas

In the first stage of the PAPM an individual may be completely unaware of a hazard (eg radon exposure the link between unprotected sex and HIV) The person may subsequently become aware of the issue but remain unengaged by it (Stage 2) Next the person faces a decision about acting (Stage 3) may decide not to act (Stage 4)

or may decide to act (Stage 5) The stages of action (Stage 6) and maintenance (Stage 7) follow (See Figure 4) According to the PAPM people pass through each stage of precaution adoption without skipping any of them It is possible for people to move backwards from some later stages to earlier ones but once they have completed the first two stages of the model they do not return to them For example a person does not move from unawareness to awareness and then back to unawareness

The PAPM bears similarities to the Stages of Change model but differs in important ways Stages of Change offers insights for addressing hard-to-change behaviors such as smoking or overeating it is less helpful when dealing with hazards that have recently been recognized or precautions that are newly available The PAPM recognizes that people who are unaware of an issue or are unengaged by it face different barriers from those who have decided not to act The PAPM prompts practitioners to develop intervention strategies that take into account the stages that precede active decision-making

Interpersonal Level

At the interpersonal level theories of health behavior assume individuals exist within and are influenced by a social environment The opinions thoughts behavior advice and support of the people surrounding an individual influence his or her feelings and behavior and the individual has a reciprocal effect on those people The social environment includes family members coworkers friends health professionals and others Because it affects behavior the social environment also impacts health Many theories focus at the interpersonal level but this monograph highlights Social Cognitive Theory (SCT) SCT is one of the most frequently used and robust health behavior theories It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior

Social Cognitive Theory (SCT) Social Cognitive Theory (SCT) describes a dynamic ongoing process in which personal factors environmental factors and human behavior exert influence upon each other

T H E O

R I E S

A N

D A

P P

L I C A

T I O N

S

According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

According to SCT three main factors affect the likelihood that a person will change a health behavior (1) self-efficacy (2) goals and (3) outcome expectancies If individuals have a sense of personal agency or self-efficacy they can change behaviors even when faced with obstacles If they do not feel that they can exercise control over their health behavior they are not motivated to act or to persist through challenges9 As a person adopts new behaviors this causes changes in both the environment and in the person Behavior is not simply a product of the environment and the person and environment is not simply a product of the person and behavior

Table 5 Social Cognitive Theory

SCT evolved from research on Social Learning Theory (SLT) which asserts that people learn not only from their own experiences but by observing the actions of others and the benefits of those actions Bandura updated SLT adding the construct of self-efficacy and renaming it SCT (Though SCT is the dominant version in current practice it is still sometimes called SLT) SCT integrates concepts and processes from cognitive behaviorist and emotional models of behavior change so it includes many constructs (See Table 5) It has been used successfully as the underlying theory for behavior change in areas ranging from dietary change10

to pain control11

Reciprocal determinism describes interactions between behavior personal factors and environment where each influences the others Behavioral capability states that to perform a behavior a person must know what to do and how to do it Expectations are the results an individual anticipates from taking action Bandura considers self-efficacy the most important personal factor in behavior change and it is a nearly ubiquitous construct in health behavior theories Strategies for increasing self-efficacy include setting incremental goals (eg exercising for 10 minutes each day) behavioral contracting (a formal contract with specified goals and rewards) and monitoring and reinforcement (feedback from self-monitoring or record keeping)

rather than through their own experience Reinforcements are responses to behavior that affect whether or not one will repeat it Positive reinforcements (rewards) increase a personrsquos likelihood of repeating the behavior Negative reinforcements may make repeated behavior more likely by motivating the person to eliminate a negative stimulus (eg when drivers put the key in the carrsquos ignition the beeping alarm reminds them to fasten their seatbelt) Reinforcements can be internal or external Internal rewards are things people do to reward themselves External rewards (eg token incentives) encourage continued participation in multiple-session programs but generally are not effective for sustaining long-term change because they do not bolster a personrsquos own desire or commitment

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Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person behavior and the environment in which the behavior is performed

Consider multiple ways to promote behavior change including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-efficacy Confidence in onersquos ability to take action and overcome barriers

Approach behavior change in small steps to ensure success be specific about the desired change

Observational learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of othersrsquo behavior

Offer credible role models who perform the targeted behavior

Reinforcements Responses to a personrsquos behavior that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives

Observational learning or modeling refers to change Figure 5 illustrates how self-to the process whereby people learn efficacy environmental and individual through the experiences of credible others factors impact behavior

Figure 5 An Intergrative Model

Behavioral beliefs and their

evaluative aspects

Normative beliefs and motivation

to comply

Efficacy beliefs

Attitude

Norm

Self-efficacy

Skills

Intention Behavior

Environmental constraints

Other individual difference variables

Personality traits

Attitudes toward targets

External variable

Demographic variables

A university in a rural area develops a church-based intervention to help congregation members change their habits to meet cancer risk reduction guidelines (behavior) Many members of the church have low incomes are overweight rarely exercise eat foods that are high in sugar and fat and are uninsured (personal factors) Because of their rural location they often must drive long distances to attend church visit health clinics or buy groceries (environment)

The program offers classes that teach healthy cooking and exercise skills (behavioral capability) Participants learn how eating a healthy diet and exercising will benefit them (expectations) Health advisors create contracts with participants setting incremental goals (self-efficacy) Respected congregation members serve as role models (observational learning) Participants receive T-shirts recipe books and other incentives and are taught to reward themselves by making time to relax (reinforcement) As church members learn about healthy lifestyles they bring healthier foods to church reinforcing their healthy habits (reciprocal determinism)

The conceptual frameworks in this section offer strategies for intervening at the community level

bull Community Organization and Other Participatory Models emphasize community-driven approaches to assessing and solving health and social problems

bull Diffusion of Innovations Theory addresses how new ideas products and social practices spread within an organization community or society or from one society to another

bull Communication Theory describes how different types of communication affect health behavior

Community Organization and Other Participatory Models Community organizing is a process through which community groups are helped to identify common problems mobilize resources and develop and implement strategies to reach collective goals Strict definitions of community organizing assume that the community itself identifies the problems to address (not an outside change agent) Public health professionals often adapt the methods of community organizing to launch programs that reflect the priorities of community members but may not be initiated by them Community organizing projects that start with the communityrsquos priorities rather than an externally imposed agenda are more likely to succeed

Community organizing is consistent with an ecological perspective in that it recognizes multiple levels of a health problem It can be integrated with SCT-based strategies that take into account the dynamic between personal factors environmental factors and human behavior Theories of social

networks and social support (exploring the influence of social relationships on health decision making and behavior) can be used to adapt community organizing strategies to health education goals Social systems theory (exploring how organizations in a community interact with each other and the outside world) is also useful for this purpose

Community organizing is not a single mode of practice it can involve different approaches to effecting change Jack Rothman14 produced the best-known classification of these change models describing community organizing according to three general types locality development social planning and social action These models sometimes overlap and can be combined

bull Locality development (or community development) is process oriented With the aim of developing group identity and cohesion it focuses on building consensus and capacity

bull Social planning is task oriented It stresses problem solving and usually relies heavily on expert practitioners

bull Social action is both process and task oriented Its goals are to increase the communityrsquos capacity to solve problems and to achieve concrete changes that redress social injustices

The different approaches broadly classified as community organizing share in common several concepts that are key to achieving and measuring change (See Table 6) Empowerment describes a social action process through which individuals organizations or communities gain confidence and skills to improve their quality of life15 Community capacity refers to

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Community Level

Initiatives serving communities and populations not just individuals are at the heart of public health approaches to preventing and controlling disease Community-level models explore how social systems function and change and how to mobilize community members and organizations They offer strategies that work in a variety of settings such as health care institutions schools worksites community groups and government agencies Embodying an ecological perspective community-level models address individual group institutional and community issues

Communities are often understood in geographical terms but they can be defined by other criteria too For instance there are communities of shared interests (eg the artistsrsquo community) or collective identity (eg the African American community) When planning community-level interventions it is critical to learn about

the communityrsquos unique characteristics This is particularly true when addressing health issues in ethnically or culturally diverse communities

Comprehensive health promotion programs often use advocacy techniques to help support individual behavior change with organizational and regulatory change In recent years innovative tools and methods for evaluation and measurement have been developed to capture the successes of community-level health promotion efforts12 13

Tobacco controlsmoking prevention is one area where programs have been extensively evaluated Local tobacco control initiatives typically pursue four concurrent goals (1) raising the priority of smoking as a health concern (2) helping community members to change smoking behavior (3) strengthening legal and economic deterrents to smoking and (4) reinforcing social norms that discourage smoking This multi-level approach has been proven very effective

24

T H E O

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Potential Change StrategiesTerm Definition

Community members assume which people gain mastery over

Empowerment A social action process through greater power or expand their

their lives and their communities power from within to create desired changes

Community members participate Community Characteristics of a community that actively in community life gaining

around and address problems capacity affect its ability to identify mobilize

leadership skills social networks and access to power

Community members develop members as equal partners reflects

Participation Engagement of community leadership skills knowledge and

the principle ldquoNever do for others resources through their what they can do for themselvesrdquo involvement

Community members create where the people arerdquo

Relevance Community organizing that rdquostarts their own agenda based on felt needs shared power and awareness of resources

Community members participate realizable targets for change that

Issue selection Identifying immediate specific and in identifying issues targets are

unify and build community strength chosen as part of a larger strategy

Community members discuss the Critical Awareness of social political and root causes of problems and plan

social problems consciousness economic forces that contribute to

actions to address them

Table 6 Community Organization

characteristics of a community that allow The social action model differs from other it to identify social problems and address forms of community intervention in that it them (eg trusting relationships between is grassroots based conflict oriented and neighbors civic engagement) Participation geared to mobilizing disadvantaged people in the organizing process helps community to act on their own behalf16 Goals vary but members to gain leadership and problem- typically include policy and other significant solving skills Relevance involves activating changes that participants have identified as participants to address issues that are important Largely based on the organizing important to them Issue selection entails work of Saul Alinsky and the Industrial Areas pulling apart a web of interrelated problems Foundation17 this approach employs direct-into distinct immediate solvable pieces action strategies as the primary means of Critical consciousness emphasizes helping fostering change It focuses on building community members to identify the root power and encouraging community causes of social problems members to develop their capacities

as active citizens18

In a social action approach to community Media Advocacy is an essential tactic in organizing self-interest is seen as the community organizing It involves using the motivation for action community members mass media strategically to advance public become involved when they see that it will policies20 Because the media bring attention benefit them to take action and targeted to specific issues they set the agenda for the institutions are willing to make changes public and policy makers The media often when they believe it is in their self-interest present health information in medical terms to do so Community organizing seeks to focusing on technological breakthroughs and expand participantsrsquo sense of self-interest personal health habits Media advocacy to an ever-wider sphere from the assumes the root of most health problems is individual or family level to their block not that people lack information but that they neighborhood city state and so on19 lack the power to change social and economic Participants grow through this process conditions It seeks to balance news coverage learning to take an active role in shaping by framing issues to emphasize social the future of their communities economic and politicalmdashrather than personal

and behavioralmdashinfluences on health21

Responding to high rates of cancer among African Americans a health department wishes to increase consumption of fresh fruits and vegetables in a low-income urban neighborhood The department surveys community members to find out why they do not eat more fruits and vegetables They learn there are few supermarkets within easy walking distance and residents shop at local stores that do not offer fresh affordable produce Many do not own cars they must take the bus spend money on taxis or carry shopping bags for blocks to shop at the supermarket

The health department contacts a community-based organization that has been working to improve neighborhood conditions and shares the findings with them (participation) The organizationrsquos leaders invite department staff to attend a community meeting where residents discuss why there are fewer supermarkets in low-income neighborhoods (critical consciousness) Residents say they would buy healthier less expensive foods at the supermarket if they could get a ride home (relevance) The community organization decides to organize a campaign to convince the local supermarket to start a shuttle service (issue selection)

The health department trains residents to assess the potential cost and ridership of the shuttle service (community capacity) Residents plan an event and invite the media They line up in front of the supermarket with shopping carts and signs and explain both the problem and the potential solution to reporters (media advocacy) Stories appear in the local newspapers The supermarketrsquos management meets with community residents and tells them the market loses thousands of dollars each year due to stolen shopping carts Residents explain that the store will have fewer shopping cart losses if they start a shuttle (self-interest) The supermarket agrees to give free rides to inner-city shoppers Through their success residents gain skills and confidence and are inspired to think about other ways to strengthen their community (empowerment)

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In participatory action research the people who are being studied take an active role in some or all phases of the research Participatory research builds an alliance between professional researchers and lay participants and enables a dialogue between them22 When planning and implementing health programs the programrsquos beneficiaries help to direct the type of inquiry collect and analyze data imagine possible solutions and evaluate

the costs and benefits of each choice They engage in a learning process both checking and complementing expert knowledge One example of participatory action research is the NCIrsquos COMMIT program which explored whether implementing an intervention through community organizations would result in a higher ldquoquit raterdquo among heavy smokers than in the comparison communities23 24

The CDC Task Force on the Guide to Community and Preventive Services created an organizing logic framework to illustrate how community-level factors influence health status (See Figure 6) They noted that disparities in access to health care behaviors in response to illness exposure to environmental and occupational hazards health promotion and disease prevention behaviors and experience of stress societal support and social cohesion all contribute to disparities in health status Therefore community-level interventions that address

population health until effective programs are broadly diffused and disseminated Multiple critiques including one by the National Cancer Policy Board suggest that failing to implement proven methods of cancer prevention and early detection results in tens of thousands of premature deaths each year26 Diffusion expands the number of people who are exposed to and reached by successful interventions strengthening their public health impact

Diffusion of Innovations Theory addresses neighborhood conditions employment how ideas products and social practices opportunities behavioral norms opportunities that are perceived as ldquonewrdquo spread

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26 Figure 6 Sociocultural Environment Logic Framework

Guide to Community Preventive Services Sociocultural Environment Logic Framework

DETERMINANTS IMMEDIATE OUTCOMES HEALTH OUTCOME

EQUITY and SOCIAL JUSTICE

1 Neighborhood Living Conditions

for education and training and access to health promotion prevention and care are key to addressing health disparities25 The model shows elements and associations at play in translating theory into research and action

throughout a society or from one society to another According to the late EM Rogers diffusion of innovations is ldquothe process by which an innovation is communicated through certain channels over time among the members of a social systemrdquo27 Diffusion Theory has been used to study the adoption of a wide range of health behaviors and programs including condom use smoking cessation and use of new tests and technologies by health practitioners Table 7 defines concepts that are central to this theory

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SOCIETAL RESOURCES

Standard of living Culture and history Social institutions Built environments Political structures Economic systems

Technology

4

Community Development and Employment Opportunities

2

3 Civic Engagement and Participation in

Decision-Making

Diffusion of Innovations In public health and health promotion practitioners who want to make efficient use of resources must attend to the reach adoption implementation and maintenance of programs It is not enough to develop

HEALTHIER COMMUNITIES

innovative programs to reduce the burden of cancer these programs must be disseminated Diffusion of innovations that prevent disease widely Cancer control measures will not and promote health requires a multilevel realize their full potential for improving change process that usually takes place in

Prevaling Community Norms Customs and Processes

Opportunities for Education and Developing Capacity

PHYSICAL ENVIROMNMENT

Natural Resources Table 7 Concepts in Diffusion of Innovations5

A pathway that will not be examined

HEALTHY POPULATION

ConceptSOCIETAL RESOURCES concerns the presence of essential resources Health Promotion Prevention

and Care Opportunities

Innovation6 while EQUITY and SOCIAL JUSTICE

concerns the distribution Communication channelsLinks 1-6 indicate strategic

within the population of those resources

points for intervention Social system

Time

Source Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

Definition

An idea object or practice that is thought to be new by an individual organization or community

The means of transmitting the new idea from one person to another

A group of individuals who together adopt the innovation

How long it takes to adopt the innovation

diverse settings through different strategies At the individual level adopting a health behavior innovation usually involves lifestyle change At the organizational level it may entail starting programs changing regulations or altering personnel roles At a community level diffusion can include using the media advancing policies or starting initiatives According to Rogers a number of factors determine how quickly and to what extent an innovation will be adopted and diffused By considering the benefits of an innovation (see Table 8) practitioners can position it effectively thereby maximizing its appeal

Specifically

bull The relative advantage of an innovation shows its superiority over whatever it replaces

bull Compatibility is an appropriate fit with the intended audience

bull Complexity has to do with how easy it is to implement the innovation

bull Trialability pertains to whether it can be tried on an experimental basis

bull Observability reflects whether the innovation will produce tangible results

Effective diffusion requires practitioners to use both informal and formal communications channels and a spectrum of strategies for different settings Disseminating an innovation in a variety of ways increases the likelihood that it will be adopted and institutionalized Communication usually should include both mass media and interpersonal interactions Through the two-step flow of communication information from the media moves in two stages First opinion leaders who pay close attention to the media receive the information Second they convey their own interpretations as well as the media content to others This process highlights the value of social networks for influencing adoption decisions

Rogers described the process of adoption as a classic ldquobell curverdquo with five categories of adopters innovators early adopters early majority adopters late majority adopters and laggards When an innovation is introduced the majority of people will either be early majority adopters or late majority adopters fewer will be early adopters or laggards and very few will be innovators (the first people to use the innovation) By identifying the

A university designs a program to help elementary school children cultivate healthy lifestyle habits and avoid chronic disease The program has many components it addresses the foods that children eat by modifying the fat and sugar content of school lunches it teaches important health information through a classroom-based health education curriculum and it encourages physical activity through a physical education component It is highly successful follow-up studies show that children who went through the program in elementary school continue to have healthier habits in their adolescence than those who did not go through the program

The fact that the program is successful is not enough to ensure it will change elementary school practices To achieve a broader impact the program must diffuse to other sites Program planners may seek to demonstrate the relative advantage of the program by emphasizing its positive outcomes They may try to show its compatibility by demonstrating that state policy-makers (eg the state Board of Education) have approved its materials The programrsquos complexity can be limited by creating user-friendly materials for teachers and cafeteria workers By making the materials available on a Web site they can enhance its trialability Professional demonstrations of the program components can create an element of observability

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characteristics of people in each adopter category practitioners can more effectively plan and implement strategies that are customized to their needs

Communication Theory Communication theory explores ldquowho says what in which channels to whom and with what effectsrdquo It investigates how messages are created transmitted received and assimilated When applied to public health

Public health communications should represent an ecological perspective and foster multilevel strategies such as tailored messages at the individual level targeted messages at the group level social marking at the community level media advocacy at the policy level and mass media campaigns at the population level29 Public health communications can increase knowledge and awareness of a health issue influence perceptions beliefs and attitudes that

Table 8 Key Attributes Affecting the Speed and Extent of an Innovationrsquos Diffusion

Attribute

Relative advantage

Compatibility

Complexity

Trialability

Observability

Key Question

Is the innovation better than what it will replace

Does the innovation fit with the intended audience

Is the innovation easy to use

Can the innovation be tried before making a decision to adopt

Are the results of the innovation observable and easily measurable

problems the central question theories of factor into social norms prompt action communication seek to answer is ldquoHow do demonstrate or illustrate healthy skills communication processes contribute to or discourage behavior changerdquo Focused on improving the health of communities rather than examining the underlying processes of communication public health communications is the scientific development strategic dissemination and evaluation of relevant accurate accessible and understandable health information communicated to and from intended audiences to advance the publicrsquos health28

increase support for services debunk misconceptions and strengthen organizational relations30 On the other hand without supports in the social and physical environment health communications alone may not be enough to sustain individual-level behavior changes may not be effective for relaying complex health messages and cannot compensate for lack of access to health care or healthy environments31

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Since other communication strategies are discussed elsewhere in this monograph this section examines the role of mass media in public health interventions The media are interconnected large-scale organizations that gather process and disseminate news information entertainment and advertising worldwide Whether they are small operations such as a neighborhood newspaper or large corporations employing tens of thousands of people the media influence almost every aspect of human life economic political social and behavioral

Media Effects The outcomes of media dissemination of ideas images themes and stories are termed media effects Media effects research investigates not only how the media influence the knowledge opinions attitudes and behaviors of audience members but also how audience members affect the media Because audience members are active seekers and users of health information the content transmitted through the media reflects their needs interests and preferences Two questions are central to understanding the effects of media on audience members 1) What factors affect the likelihood that a person will be exposed to a given message 2) How do media effects vary with the amount of exposure to that message32

Funding is a primary factor that determines whether or not audience members will be exposed to a message through the mass media since money is needed to buy media time and space Many public health programs do not have large budgets so they often must rely on strategies for free distribution Options may include public service announcements embedding health messages in entertainment programs (eg soap operas) or promoting news coverage of public health topics in print and electronic media Community institutions can adopt and disseminate messages and

social networks can also generate excitement about some messages depending on their content33

How often do people need to hear a message before it influences their beliefs or behaviors This depends on several factors Characteristics of target audiences (eg their readiness for change the ways they process information) the complexity of the health issue the presence of competing messages and the nature of the health message influence the relationship between exposure to a health message and an outcome effect Repeated exposure to a message especially when it is delivered through multiple channels may intensify its impact on audience members34

Planners often assume that a certain percentage of the target audience will be exposed to a message and that another fraction of those who receive the message will be engaged by it Yet there are several possible paths through which a health communications message can influence someonersquos beliefs andor behaviors These include immediate learning (people learn directly from the message) delayed learning (the impact of the message is not processed until some time after it has been conveyed) generalized learning (in addition to the message itself people are persuaded about concepts related to the message) social diffusion (messages stimulate discussion among social groups thereby affecting beliefs) and institutional diffusion (messages instigate a response from public institutions that reinforces the messagersquos impact on the target audience)35

Agenda Setting The mass media can illuminate and focus attention on issues helping to generate public awareness and momentum for change A major focus of communications research

has been on how the mass media influence public opinion especially about politics and policymaking Agenda setting involves setting the media agenda (what is covered) the public agenda (what people think about) and the policy agenda (regulatory or legislative actions on issues)36 (See Table 9) Research on agenda setting has shown that the amount of media coverage an issue receives correlates strongly with the publicrsquos opinion of how important that issue is

An axiom underlying this area of study is that mass media may not tell us what to think but they are surprisingly effective in telling us what to think about A critical construct of agenda setting however reinterprets this idea Framing is a process in which someone tells the audience what aspect of the story is

important In other words they tell the audience not only what to think about but how to think about it The way facts are packaged to tell a story creates the frame By framing stories to emphasize social and environmental factors that affect health public health advocates can use the media to pressure decision makers to develop and support healthy policies

New Communication Technologies

New communication technologies have opened an extraordinary range of avenues for influencing health behavior ldquoE-healthrdquo (one element of new communication technologies) is the use of emerging information and communication technology especially the Internet to improve or enable

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Media agenda setting

Public agenda setting

Policy agenda setting

Problem definition

Framing

Definition

Institutional factors and processes influencing how the media define select and emphasize issues

The link between issues covered in the media and the publicrsquos priorities

The link between issues covered in the media and the legislative priorities of policy makers

Factors and process leading to the identification of an issue as a ldquoproblemrdquo by social institutions

Selecting and emphasizing certain aspects of a story and excluding others

Potential Change Strategies

Understand media professionalsrsquo needs and routines for gathering and reporting news

Use media advocacy or partnerships to raise public awareness of key health issues

Advocate for media coverage to educate and pressure policy makers about changes to the physical and social environment needed to promote health

Community leaders advocacy groups and organizations define an issue for the media and offer solutions

Advocacy groups ldquopackagerdquo an important health issue for the media and the public

Table 9 Agenda Setting Concepts Definitions and Applications

health and health care The term refers to an emerging field in the intersection of medical informatics public health and business37

It bridges clinical and non-clinical sectors and includes both individual and population health-oriented tools38 E-health communication strategies include but are not limited to health information on the Internet online support groups online collaborative communities information tailored by computer technologies educational computer games computer-controlled in-home telephone counseling and patient-provider e-mail contact39

Major benefits of e-health strategies are increased reach (the ability to communicate to broad geographically dispersed audiences) asynchronous communication (interaction not bounded by having to communicate at the same time) the ability to integrate multiple communication modes and formats (eg audio video text graphics) the ability to track preserve and analyze communication (computer records of interaction analysis of interaction trends) user control of the communication system (the ability to customize programs to user specifications) and interactivity (eg increased capacity for feedback)40

Educational and behavioral interventions

Community organizing approaches have been used to coordinate Internet-based campaigns through wwwMeetupcom (a technology platform that helps people self-organize local gatherings)

Innovative e-health projects are expanding the range of tools that planners can use to develop cancer control and other interventions For instance NCIrsquos Cancer Control Planet httpcancercontrolplanet cancergov links public health professionals to comprehensive cancer control resources NCI also has published data from its Health Information National Trends Survey (HINTS) on the Web at httpcancercontrolcancergov hints The HINTS program helps survey researchers program planners and social scientists understand how adults 18 years and older are using different communication channels including the Internet For example according to recent HINTS data when asked where they would go first if they had a strong need to get information about cancer 34 percent of respondents said they would go to the Internet

The HINTS data illustrate consumersrsquo increasing reliance on the Internet as an easily accessible source of health information The Internet has been characterized as a ldquohybrid technologyrdquo because it has the potential to reach millions of people with information that can be tailored to individual needs and preferences41 E-health interventions frequently offer information education and support directly to consumers For example the Association of Online Cancer Resources (ACOR) a collection of online communities designed to provide timely and accurate information in a supportive environment is one case in point ACOR delivers 18 million cancer messages each week (httpwwwacororg)

Not all e-health interventions are Web-based Computer applications have also allowed new uses of traditional health communications media such as print and telephone Tailored print communications (TPCs) and telephone-delivered interventions (TDIs) are two examples that have the potential for reaching linguistically and culturally diverse audiences TPCs are printed materials created especially for an individual based on relevant information about that person Over 40 studies of TPCs have been conducted on a wide range of health topics including diet exercise smoking cessation mammography and prostate cancer most have found positive outcomes evidence TDIs include a range of human-delivered counseling and reminder interventions delivered using the telephone and computer-generated voice response systems Studies indicate that TDIs are effective across different populations and health topics but do not have a broad-based reach They have not been widely used by diverse populations42

Interactive games offer another vehicle for intervention Lieberman et al designed a series of Nintendo video games to improve childrenrsquos and adolescentsrsquo prevention and self care behaviors for asthma diabetes smoking prevention and other health topics

(see Figure 7)43 The games were based on well-established theories of learning and behavior change such as Social Cognitive Theory They reduced playersrsquo urgent care and emergency medical visits by as much as 77 percent44 Though research has demonstrated the effectiveness of some new communications technologies further inquiry is needed into the mechanismsrsquo underlying success45

Opportunities are increasing for people to gain free access to the Internet via libraries and kiosks46 Unequal access remains problematic however Significant gaps in Internet usage between Caucasians African Americans and Hispanics persist47 and people with lower levels of educational attainment are also less likely to have Internet access Because the Internet is a text-based medium literacy issues that make it difficult for people to read print materials are also barriers to accessing Web-based information There is danger that new computer technologies could worsen existing inequities in health status for diverse populations It is therefore important to involve community members in planning e-health interventions and to offer them ongoing training and support for using these emerging communications tools48

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employing new communication technologies are forging new ground and therefore benefit from the perspective provided by theories of health behavior Like communications in other media e-health interventions can address issues at the individual group or communitysocietal level different theories may be appropriate depending on the projectrsquos goals For example computer-tailored print materials encouraging individuals to eat more fruits and vegetables could be designed using the Stages of Change Model Online support groups may apply theories of social support and social networks

Figure 7

An Asthma Self-Management Video Game for Children (Bronkie the Bronchiasaurus)

Box art reproduction used by permission of Health Hero Network Copyright copy 1994 by Health Hero Network All rights reserved

Putting Theory And Practice Together Part 3

35

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Planning Models

When practitioners begin the process of planning an intervention to promote health or change health behavior theory helps them interpret the situation and guides their decisions about what design procedures and measurement indicators to select Depending on the unit of practice (eg individuals groups organizations community) and the nature of the health problem different theoretical approaches may be appropriate Practitioners can find that using more than one theory to address a problem produces a stronger impact This is particularly true when planning comprehensive health promotion programs that address multiple levels (eg individual organizational community) of a health problem

Planning models such as PRECEDEshyPROCEED and social marketing help practitioners develop programs step by step integrating multiple theories to explain and address health problems Practitioners begin by using theory to develop a set of assumptions about factors contributing to a health problem They then use research to test adjust and add to these assumptions Armed with a theoretical framework and situation-specific research findings practitioners design a targeted intervention strategy This includes designing an evaluation to gauge whether or not the approach is effective and choosing realistic actionable goals that define in advance what programmatic success will look like

Research (into the needs of the population resources available and the situation in which the health problem occurs) is a central feature of comprehensive planning models Theory helps planners think about what questions to ask throughout program

planning implementation and evaluation phases During program planning they explore the needs and resources of the population and learn how to design effective materials and strategies During implementation they seek to build and continually improve the program After it ends they assess what short-term and long-term effects the program has had on the health problem and its contributing factors

Both social marketing and the PRECEDEshyPROCEED model instruct the practitioner to begin the planning process by assessing the target audiencersquos needs at multiple levels of a health problem In social marketing this preliminary investigation involves conducting consumer research and market analysis In PRECEDE-PROCEED it includes carrying out epidemiological assessment behavioral educational environmental and organizational diagnosis and administrative and policy assessment Both planning models combine behavior change theories for greater impact and use them as a basis for evaluation These planning models are described in greater detail in the sections that follow

Social Marketing Social marketing uses marketing techniques to influence the voluntary behavior of target audience members for health benefit It is distinct from health education in that it goes beyond informing or persuading people to reinforcing behavior with incentives and other benefits It also differs from commercial marketing because the people who gain from it are members of the target audience Another difference is that the marketing organization defines success in terms of positive effects on society

Social marketing is not a theory but an approach to promoting health behavior

Alan Andreason defines it as ldquothe application of commercial marketing technologies to the analysis planning execution and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of societyrdquo49

This process creates a voluntary exchange between a marketing organization and members of a target audience based on mutual fulfillment of self-interest In other words the marketing organization exists to fulfill its mission (as defined by the organizationrsquos leadership) and the target audience members act in their own interests

Social marketing programs are generally ldquoconsumer-drivenrdquo not expert-driven They are targeted to serve a defined group of people To avoid delineating the target market in an overly broad manner social marketing practitioners segment a larger heterogeneous target market into smaller subgroups Market segmentation is the process of dividing a target audience into these more homogenous subgroups with distinct unifying characteristics and needs For example factors such as regional location ethnicity gender exercise habits readiness for change or media habits could be used to segment the larger audience of ldquosmokersrdquo Social marketing seeks to identify patterns that distinguish one target group from another to effectively target marketing strategies

The social marketing process involves identifying an effective ldquomarketing mixrdquo (ldquoThe four Psrdquo) of product price place and promotion The optimal marketing mix produces a timely exchange that heightens benefits reduces barriers and offers a better choice than the competition The social marketer explores what benefits are of most interest to target market

members and develops strategies and methods accordingly The four Ps of the marketing mix are

bull Product (the right kind of behavioral change) includes not only the behavior that is being promoted but also the benefits that go along with it

bull Price (an exchange of benefits and costs) refers to barriers or costs involved in adopting the behavior (eg money time effort)

bull Place (making new behaviors easy to do) is about making the ldquoproductrdquo accessible and convenient It means delivering benefits in the right place at the right time

bull Promotion (delivering the message to the audience) is how the practitioner notifies the target market of the product as well as its benefits reasonable cost and convenience

Ideally social marketing interventions begin with formative research (also called audience or consumer research) to understand the target marketrsquos perceptions needs and wants concerning the health behavior Formative research includes learning about consumersrsquo current behavior what enables it and what reinforces it Practitioners also conduct a second type of research competitive analysis (also called environmental analysis) to learn about the environment in which members of the target market are making behavior decisions This analysis examines competing behaviors that are being promoted to the target market (For example messages encouraging people to eat convenient inexpensive fast foods compete with messages about eating 5 fruits and vegetables a day) It also investigates how consumersrsquo decisions are shaped by factors such as their social and physical surroundings or their economic situation

37

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Evaluation is a critical and ongoing component of social marketing programs Formative research helps practitioners to develop and refine concepts messages products services pricing and distribution channels before they are fully implemented Marketers often use qualitative methods such as focus groups or key informant interviews to pre-test marketing concepts messages and materials in a cost-effective manner They may also pilot-test materials with individuals who share characteristics of the target market in order to verify their effectiveness identify diverse channels for delivering the message and measure outcomes Process evaluation methods are used to track program outputs and processes during implementation Social marketers also conduct summative research often in the form of outcomes monitoring This analysis

compares the programrsquos program objectives with its immediate and long-term outcomes to determine what worked what didnrsquot and whether the program was cost-effective

Social marketing programs are most successful when they are implemented using a research-driven process then consumer research can help to adjust program messages and outputs The social marketing process includes four stages planning and strategy development development of pretesting concepts messages and materials implementation assessment of in-market effectiveness and feedback to the first stage (See Figure 8) Within each stage there is a constant feedback loop between research and planning

As an approach that promotes behavior change through voluntary exchange and positive reinforcement social marketing borrows substantively from behavior change theory Behavioral theory offers insights into the current behavior of target market members and what might influence or change that behavior For example a social marketer who references Social Cognitive Theory might examine how self-efficacy and expectations about the outcome of a behavior factor into certain health practices within a target market

The California 5 A Day Campaign which was the model for the national 5 A Day program50 employs social marketing to increase Californiansrsquo consumption of fruit and vegetables through strategies such as supermarket point-of-purchase interventions industry promotional support media outreach and community programs51

Several features of this program have been well-received52 First it has a focused goal

preparing them psychological cost of ldquoworryingrdquo about getting the recommended number of servings)

bull Place Grocery stores and other points of purchase (the 5 A Day message and healthy foods compete against unhealthy products for space and attention)

bull Promotion Branding the 5 A Day campaign to increase awareness (eg using a slogan and compelling images that are easy to recall)

Distribution channels include mass media advertising public service announcements newsletters the Internet magazines press conferences outreach activities special events and community-based groups such as churches Regular monitoring and evaluation help to assess the reach and impact of messages efficient use of time labor and capital resources and program costsbenefits

39

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E R

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Figure 8 Social Marketing Wheel

to increase fruit and vegetable consumption by raising awareness of the health benefits PRECEDE-PROCEEDSecond its approach is built on an PRECEDE-PROCEED is a planning model

not a theory It does not predict or explain 1 established theoretical frameworkmdashthePlanning and Stages of Change model Third messages Strategy factors linked to the outcomes of interest

Development were designed and disseminated using but offers a framework for identifying intervention strategies to address these factors Developed by Green Kreuter

consumer-driven communications strategies Fourth formative research (mall

Developing and Pretesting

intercept interviews focus groups and4 Concepts and associates53 PRECEDE-PROCEEDMessages baseline survey data) helped the planners provides a road map for designing health

education and health promotion programs and Materials to understand their audiences and improve

Assesing messages Lastly the program uses the four Ps of social marketing2 It guides planners through a process that

starts with desired outcomes and works Effectiveness and Making Refinements

3 Implementing the Program

bull Product Consuming more fruits and vegetables each day to minimize the risk of cancer and improve health status

bull Price The costs of eating a healthier diet (eg financial cost of buying fruits and vegetables time cost of shopping for and

backwards to identify a mix of strategies for achieving objectives (See httplgreennetindexhtml)

Because the model views health behavior as influenced by both individual and environmental forces it has two distinct parts an ldquoeducational diagnosisrdquo

36

T H E O

R Y

AT

A G

L A N

C E

Planning Models

When practitioners begin the process of planning an intervention to promote health or change health behavior theory helps them interpret the situation and guides their decisions about what design procedures and measurement indicators to select Depending on the unit of practice (eg individuals groups organizations community) and the nature of the health problem different theoretical approaches may be appropriate Practitioners can find that using more than one theory to address a problem produces a stronger impact This is particularly true when planning comprehensive health promotion programs that address multiple levels (eg individual organizational community) of a health problem

Planning models such as PRECEDEshyPROCEED and social marketing help practitioners develop programs step by step integrating multiple theories to explain and address health problems Practitioners begin by using theory to develop a set of assumptions about factors contributing to a health problem They then use research to test adjust and add to these assumptions Armed with a theoretical framework and situation-specific research findings practitioners design a targeted intervention strategy This includes designing an evaluation to gauge whether or not the approach is effective and choosing realistic actionable goals that define in advance what programmatic success will look like

Research (into the needs of the population resources available and the situation in which the health problem occurs) is a central feature of comprehensive planning models Theory helps planners think about what questions to ask throughout program

planning implementation and evaluation phases During program planning they explore the needs and resources of the population and learn how to design effective materials and strategies During implementation they seek to build and continually improve the program After it ends they assess what short-term and long-term effects the program has had on the health problem and its contributing factors

Both social marketing and the PRECEDEshyPROCEED model instruct the practitioner to begin the planning process by assessing the target audiencersquos needs at multiple levels of a health problem In social marketing this preliminary investigation involves conducting consumer research and market analysis In PRECEDE-PROCEED it includes carrying out epidemiological assessment behavioral educational environmental and organizational diagnosis and administrative and policy assessment Both planning models combine behavior change theories for greater impact and use them as a basis for evaluation These planning models are described in greater detail in the sections that follow

Social Marketing Social marketing uses marketing techniques to influence the voluntary behavior of target audience members for health benefit It is distinct from health education in that it goes beyond informing or persuading people to reinforcing behavior with incentives and other benefits It also differs from commercial marketing because the people who gain from it are members of the target audience Another difference is that the marketing organization defines success in terms of positive effects on society

Social marketing is not a theory but an approach to promoting health behavior

Alan Andreason defines it as ldquothe application of commercial marketing technologies to the analysis planning execution and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of societyrdquo49

This process creates a voluntary exchange between a marketing organization and members of a target audience based on mutual fulfillment of self-interest In other words the marketing organization exists to fulfill its mission (as defined by the organizationrsquos leadership) and the target audience members act in their own interests

Social marketing programs are generally ldquoconsumer-drivenrdquo not expert-driven They are targeted to serve a defined group of people To avoid delineating the target market in an overly broad manner social marketing practitioners segment a larger heterogeneous target market into smaller subgroups Market segmentation is the process of dividing a target audience into these more homogenous subgroups with distinct unifying characteristics and needs For example factors such as regional location ethnicity gender exercise habits readiness for change or media habits could be used to segment the larger audience of ldquosmokersrdquo Social marketing seeks to identify patterns that distinguish one target group from another to effectively target marketing strategies

The social marketing process involves identifying an effective ldquomarketing mixrdquo (ldquoThe four Psrdquo) of product price place and promotion The optimal marketing mix produces a timely exchange that heightens benefits reduces barriers and offers a better choice than the competition The social marketer explores what benefits are of most interest to target market

members and develops strategies and methods accordingly The four Ps of the marketing mix are

bull Product (the right kind of behavioral change) includes not only the behavior that is being promoted but also the benefits that go along with it

bull Price (an exchange of benefits and costs) refers to barriers or costs involved in adopting the behavior (eg money time effort)

bull Place (making new behaviors easy to do) is about making the ldquoproductrdquo accessible and convenient It means delivering benefits in the right place at the right time

bull Promotion (delivering the message to the audience) is how the practitioner notifies the target market of the product as well as its benefits reasonable cost and convenience

Ideally social marketing interventions begin with formative research (also called audience or consumer research) to understand the target marketrsquos perceptions needs and wants concerning the health behavior Formative research includes learning about consumersrsquo current behavior what enables it and what reinforces it Practitioners also conduct a second type of research competitive analysis (also called environmental analysis) to learn about the environment in which members of the target market are making behavior decisions This analysis examines competing behaviors that are being promoted to the target market (For example messages encouraging people to eat convenient inexpensive fast foods compete with messages about eating 5 fruits and vegetables a day) It also investigates how consumersrsquo decisions are shaped by factors such as their social and physical surroundings or their economic situation

37

PART 3

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T T I N G

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A C

T I C E T O

G E T H

E R

Evaluation is a critical and ongoing component of social marketing programs Formative research helps practitioners to develop and refine concepts messages products services pricing and distribution channels before they are fully implemented Marketers often use qualitative methods such as focus groups or key informant interviews to pre-test marketing concepts messages and materials in a cost-effective manner They may also pilot-test materials with individuals who share characteristics of the target market in order to verify their effectiveness identify diverse channels for delivering the message and measure outcomes Process evaluation methods are used to track program outputs and processes during implementation Social marketers also conduct summative research often in the form of outcomes monitoring This analysis

compares the programrsquos program objectives with its immediate and long-term outcomes to determine what worked what didnrsquot and whether the program was cost-effective

Social marketing programs are most successful when they are implemented using a research-driven process then consumer research can help to adjust program messages and outputs The social marketing process includes four stages planning and strategy development development of pretesting concepts messages and materials implementation assessment of in-market effectiveness and feedback to the first stage (See Figure 8) Within each stage there is a constant feedback loop between research and planning

As an approach that promotes behavior change through voluntary exchange and positive reinforcement social marketing borrows substantively from behavior change theory Behavioral theory offers insights into the current behavior of target market members and what might influence or change that behavior For example a social marketer who references Social Cognitive Theory might examine how self-efficacy and expectations about the outcome of a behavior factor into certain health practices within a target market

The California 5 A Day Campaign which was the model for the national 5 A Day program50 employs social marketing to increase Californiansrsquo consumption of fruit and vegetables through strategies such as supermarket point-of-purchase interventions industry promotional support media outreach and community programs51

Several features of this program have been well-received52 First it has a focused goal

preparing them psychological cost of ldquoworryingrdquo about getting the recommended number of servings)

bull Place Grocery stores and other points of purchase (the 5 A Day message and healthy foods compete against unhealthy products for space and attention)

bull Promotion Branding the 5 A Day campaign to increase awareness (eg using a slogan and compelling images that are easy to recall)

Distribution channels include mass media advertising public service announcements newsletters the Internet magazines press conferences outreach activities special events and community-based groups such as churches Regular monitoring and evaluation help to assess the reach and impact of messages efficient use of time labor and capital resources and program costsbenefits

39

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E R

38

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R Y

AT

A G

L A N

C E

Figure 8 Social Marketing Wheel

to increase fruit and vegetable consumption by raising awareness of the health benefits PRECEDE-PROCEEDSecond its approach is built on an PRECEDE-PROCEED is a planning model

not a theory It does not predict or explain 1 established theoretical frameworkmdashthePlanning and Stages of Change model Third messages Strategy factors linked to the outcomes of interest

Development were designed and disseminated using but offers a framework for identifying intervention strategies to address these factors Developed by Green Kreuter

consumer-driven communications strategies Fourth formative research (mall

Developing and Pretesting

intercept interviews focus groups and4 Concepts and associates53 PRECEDE-PROCEEDMessages baseline survey data) helped the planners provides a road map for designing health

education and health promotion programs and Materials to understand their audiences and improve

Assesing messages Lastly the program uses the four Ps of social marketing2 It guides planners through a process that

starts with desired outcomes and works Effectiveness and Making Refinements

3 Implementing the Program

bull Product Consuming more fruits and vegetables each day to minimize the risk of cancer and improve health status

bull Price The costs of eating a healthier diet (eg financial cost of buying fruits and vegetables time cost of shopping for and

backwards to identify a mix of strategies for achieving objectives (See httplgreennetindexhtml)

Because the model views health behavior as influenced by both individual and environmental forces it has two distinct parts an ldquoeducational diagnosisrdquo

Evaluation is a critical and ongoing component of social marketing programs Formative research helps practitioners to develop and refine concepts messages products services pricing and distribution channels before they are fully implemented Marketers often use qualitative methods such as focus groups or key informant interviews to pre-test marketing concepts messages and materials in a cost-effective manner They may also pilot-test materials with individuals who share characteristics of the target market in order to verify their effectiveness identify diverse channels for delivering the message and measure outcomes Process evaluation methods are used to track program outputs and processes during implementation Social marketers also conduct summative research often in the form of outcomes monitoring This analysis

compares the programrsquos program objectives with its immediate and long-term outcomes to determine what worked what didnrsquot and whether the program was cost-effective

Social marketing programs are most successful when they are implemented using a research-driven process then consumer research can help to adjust program messages and outputs The social marketing process includes four stages planning and strategy development development of pretesting concepts messages and materials implementation assessment of in-market effectiveness and feedback to the first stage (See Figure 8) Within each stage there is a constant feedback loop between research and planning

As an approach that promotes behavior change through voluntary exchange and positive reinforcement social marketing borrows substantively from behavior change theory Behavioral theory offers insights into the current behavior of target market members and what might influence or change that behavior For example a social marketer who references Social Cognitive Theory might examine how self-efficacy and expectations about the outcome of a behavior factor into certain health practices within a target market

The California 5 A Day Campaign which was the model for the national 5 A Day program50 employs social marketing to increase Californiansrsquo consumption of fruit and vegetables through strategies such as supermarket point-of-purchase interventions industry promotional support media outreach and community programs51

Several features of this program have been well-received52 First it has a focused goal

preparing them psychological cost of ldquoworryingrdquo about getting the recommended number of servings)

bull Place Grocery stores and other points of purchase (the 5 A Day message and healthy foods compete against unhealthy products for space and attention)

bull Promotion Branding the 5 A Day campaign to increase awareness (eg using a slogan and compelling images that are easy to recall)

Distribution channels include mass media advertising public service announcements newsletters the Internet magazines press conferences outreach activities special events and community-based groups such as churches Regular monitoring and evaluation help to assess the reach and impact of messages efficient use of time labor and capital resources and program costsbenefits

39

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AT

A G

L A N

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Figure 8 Social Marketing Wheel

to increase fruit and vegetable consumption by raising awareness of the health benefits PRECEDE-PROCEEDSecond its approach is built on an PRECEDE-PROCEED is a planning model

not a theory It does not predict or explain 1 established theoretical frameworkmdashthePlanning and Stages of Change model Third messages Strategy factors linked to the outcomes of interest

Development were designed and disseminated using but offers a framework for identifying intervention strategies to address these factors Developed by Green Kreuter

consumer-driven communications strategies Fourth formative research (mall

Developing and Pretesting

intercept interviews focus groups and4 Concepts and associates53 PRECEDE-PROCEEDMessages baseline survey data) helped the planners provides a road map for designing health

education and health promotion programs and Materials to understand their audiences and improve

Assesing messages Lastly the program uses the four Ps of social marketing2 It guides planners through a process that

starts with desired outcomes and works Effectiveness and Making Refinements

3 Implementing the Program

bull Product Consuming more fruits and vegetables each day to minimize the risk of cancer and improve health status

bull Price The costs of eating a healthier diet (eg financial cost of buying fruits and vegetables time cost of shopping for and

backwards to identify a mix of strategies for achieving objectives (See httplgreennetindexhtml)

Because the model views health behavior as influenced by both individual and environmental forces it has two distinct parts an ldquoeducational diagnosisrdquo

(PRECEDE) and an ldquoecological diagnosisrdquo (PROCEED) The PRECEDE acronym stands for Predisposing Reinforcing Enabling Constructs in Educational Environmental Diagnosis and Evaluation Developed in the 1970s this component of the model posits that an educational diagnosis is needed to design a health promotion intervention just as a medical diagnosis is needed to design a treatment plan PROCEDE stands for Policy Regulatory and Organizational Constructs in Educational and Environmental Development This element was added to the framework later in 1991 to take into account the impact of environmental factors on health Together these two

components of the model help practitioners plan programs that exemplify an ecological perspective

PRECEDE-PROCEED has nine steps The first five steps are diagnostic addressing both educational and environmental issues These include (1) social assessment (2) epidemiological assessment (3) behavioral and environmental assessment (4) educational and ecological assessment and (5) administrative and policy assessment The last four comprise implementation and evaluation of health promotion intervention These include (6) implementation (7) process evaluation (8) impact evaluation and (9) outcome evaluation (See Figure 9)

During the diagnostic steps of the model practitioners employ various methods to learn about the communityrsquos perceived and actual needs as well as the regulatory context in which the intervention will operate To conduct social assessment the practitioner may use multiple data collection activities (eg key informant interviews focus groups participant observation surveys) to understand the communityrsquos perceived needs Epidemiological assessment may include secondary data analysis or original data collection to prioritize the communityrsquos health needs and establish program goals and objectives Behavioral and Environmental Assessment identifies factors both internal and external to the individual that affect the health problem Reviewing the literature and applying theory are two ways to map out these factors

bull Enabling factors which enable persons to act on their predispositions these factors include available resources supportive policies assistance and services

bull Reinforcing factors which come into play after a behavior has been initiated they encourage repetition or persistence of behaviors by providing continuing rewards or incentives Social support praise reassurance and symptom relief might all be considered reinforcing factors

In the final diagnostic step of PRECEDEshyPROCEED Administrative and Policy Assessment intervention strategies reflect information gathered in previous steps the availability of needed resources and organizational policies and regulations that could affect program implementation (See Table 10)

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Figure 9 The PRECEDE-PROCEED Model

PRECEDE

STEP 5 Administration

and Policy Diagnosis

STEP 4 STEP 3 STEP 2 STEP 1 Educational and Behavioral and Epidemiological Social

Ecological Environmental Assessment Assessment Assessment Assessment

In Educational and Ecological Assessment the practitioner identifies antecedent and reinforcing factors that must be in place to initiate and sustain change Behaviormdashsuch as reducing intake of dietary fat engaging in routine physical activity and obtaining annual mammogramsmdashis shaped by

The four remaining steps of PRECEDEshyPROCEED comprise program implementation and evaluation Before Implementation (Step 6) begins practitioners should prepare plans for evaluating the process (Step 7) impact

Predisposing Health factors

Promotion

Health Reinforcing Behavior and education factors lifestyle

Policy regulation Enabling Environment organization factors

Health Quality of life

predisposing reinforcing and enabling factors Practitioners can use individual interpersonal or community-level change theories to classify determinants of behavior

(Step 8) and outcome (Step 9) of the intervention Process Evaluation gauges the extent to which a program is being carried out according to plan Impact Evaluation looks at changes in factors (ie

into one of these three categories and rank their importance Because each type of

predisposing enabling and reinforcing

factor requires different intervention factors) that influence the likelihood that

strategies classifying them helps behavioral and environmental change will

practitioners consider how to address occur Lastly outcome evaluation looks at

Implementation Process Impact Outcome Evaluation Evaluation Evaluation

PROCEED Source Green LW Kreuter MW 1999

As Table 11 shows the individual bull Predisposing factors which motivate or interpersonal and community-level theories

provide a reason for behavior they include discussed in this monograph are mostknowledge attitudes cultural beliefs and useful when applied to PRECEDE-readiness to change PROCEEDrsquos diagnostic steps Community

community needs The three types of influencing factors include

STEP 6 STEP 7 STEP 8 STEP 9

whether the intervention has affected health and quality-of-life indicators

Planning Step Function Examples of Relevant Theory

1 Social Assessment Assesses peoplersquos views of their own needs and quality of life

Community organization

Community building

2 Epidemiological Assessment

Documents which health problems are most important for which groups in a community

Community-level theories (If the community helps to choose the health problem that will be addressed)

3 Behavioral Environmental

Assessment

Identifies factors that contribute to the health problem of interest

Interpersonal theories - Social Cognitive Theory

Theories of organizational change

Community organization

Diffusion of innovations

4 Educational Ecological

Assessment

Identifies preceding and reinforcing factors that must be in place to initiate and sustain change

All three levels of change theories - Individual - Interpersonal - Community

5 Administrative Policy

Assessment

Identifies policies resources and circumstances in the programrsquos context that may help or hinder implementation

Community-level theories - Community organization - Organizational change

organization relates to Step 1 which may entail working with communities to identify their own needs strengths resources and capacities Descriptive epidemiology is most pertinent to Step 2 but community-level theories may be relevant if the community helps to choose the health problem that will be addressed or to set priorities among health problems Theory is most directly useful when applied to steps 3 4 and 5 since these steps call upon the practitioner to make strategic decisions By using theory the practitioner can make sound choices that are based upon more than just intuition and personal judgment

Theory should guide practitionersrsquo examshyination of predisposing enabling and reinforcing factors For example the Health Belief Model suggests that certain beliefs might influence womenrsquos decisions about whether or not to get a mammogram such as perceived chances of developing cancer (perceived susceptibility) or how serious they believe cancer would be (perceived severity) Both beliefs constitute predisposing factors Other HBM constructs may identify possible perceived benefits of and barriers to screening Receiving

reassurance that they do not have cancer (perceived benefit) might be a reinforcing factor Lack of insurance coverage for screening mammography (perceived barrier) could be a negative enabling factor

By exploring the degree to which each of these factors affects womenrsquos behaviors program planners can decide how to focus program messages for a communications campaign or strategies for an administrative intervention (such as providing low- or no-cost screening or changing insurance coverage) The best way to verify and rank explanations offered by theory is to gather information directly from women in the target population Another less ideal

To make appropriate use of theory in a given situation practitioners must consider both the social or health problem at hand and the context in which the intervention will take place Once they have identified a problem they can use a planning system such as social marketing or PRECEDEshyPROCEED to identify social science theories that contribute to their understanding These theories can guide them to potential points of intervention Consulting the research literature helps practitioners to learn about the past successes or failures of intervention strategies that they consider and reflect on whether those strategies are likely to work for the current situation Pre-testing

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Table 10 Diagnostic Elements of PRECEDE-PROCEED approach is to learn by reading research and actively discussing proposed literature on women who share strategies with the target audience can characteristics with the target population also help to determine whether or not they

will be well received

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Where to Begin Choosing the Right Theories

Interventions that evolve from a comprehensive planning process build on prior research and use health behavior theories are more likely to be effective By investigating what factors influence the target populationrsquos behavior including their social and physical environments practitioners gain the raw materials they need to meet the needs of that population Theory helps practitioners to interpret the findings of their research making the leap from facts on a page to understanding the dynamic interactions between behavior and environmental context Systematic approaches to tailoring targeting implementing and evaluating programs provide practitioners with a framework for translating this insight into actions that improve health outcomes

Table 11 summarizes the focus and key concepts of each of the eight theories described in this guide Refer to this table to identify theories that help explain and address a health problem For example several theories could be used to inform the design of a program to reduce tobacco use among adolescents By scanning the ldquoFocusrdquo column one can quickly gauge which theories might apply to a particular situation For example The Stages of Change model might be very useful since it centers on individualsrsquo readiness to change On the other hand the Health Belief Model seems less promising since young people may be less concerned about long-term health problems (In fact they may not feel vulnerable to disease at all) Social Cognitive Theory could be helpful because it emphasizes the interplay between personal environmental and behavior factors Likewise Community Organization could offer perspective on activating young people

around tobacco control issues Applying step-by-step process of examining health each of these theories might look like this and behavior at multiple levels

44

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bull Stages of Change Learn more about readiness to change among adolescents who smoke in order to plan appropriate and effective cessation messages and strategies

bull Social Cognitive Theory Examine how social environment including peer attitudes influences adolescentsrsquo tobacco use What are the expectations of teens who experiment with tobacco or who use it regularly How do observational learning and reinforcement contribute to the reasons why they smoke Might these constructs help identify someone who can successfully help them to quit

bull Community Organization Consider how to involve teen smokers in developing and carrying out the program One idea might be to organize a coalition of concerned parents teachers and teens to help explore why teens smoke and identify potential solutions

The examples above offer a basic illustration of how multiple theories might be combined to address a single problem The resulting program would be a multishyfaceted multilevel effort

A Few Final Words

Once one is familiar with some contemporary theories of health behavior the challenge is to use them appropriately within a comprehensive planning process Planning systems such as social marketing and PRECEDE-PROCEED facilitate the process of developing successful programs because they lead practitioners through a

At the most basic level an ecological perspective points to two approaches to addressing health problems change peoplersquos behavior or change the environment The most powerful health promotion and behavior change interventions integrate these approaches and treat them both as essential Figure 10 illustrates that strategies intended to change peoplersquos behavior can often be derived from individual-level theories those aimed at changing the environment draw on community-level theories Theories at the interpersonal level (such as Social Cognitive Theory) lie in-between exploring the reciprocal exchanges between individuals and their environments

Practitioners who are aware of reciprocal causation (ie that individual behavior both influences and is influenced by the environment) are more likely to design multidimensional effective health promotion programs A change strategy based on individual-level theory may indirectly lead to changes in the environment (eg when individualsrsquo improved eating habits drive the cafeteria to offer healthier choices) By the same token a strategy based on community-level theory may yield improved individual health behaviors (eg when an individualrsquos involvement in a community organizing project to improve access to fruits and vegetables in the community inspires her to cook healthier foods for her family)

Theoretical frameworks offer flexible guidance for applying the abstract concepts of theory to a vast array of real circumstances By becoming familiar with

Stages of Change Model

Theory of Planned Behavior

Diffusion of Innovations

Individualsrsquo motivation and readiness to change a problem behavior

Individualsrsquo attitudes toward a behavior perceptions of norms and beliefs about the ease or difficulty of changing

How new ideas products and practices spread within a society or from one society to another

Precontemplation Contemplation Decision Action Maintenance

Behavioral intention Attitude Subjective norm Perceived behavioral control

Relative advantage Compatibility Complexity Trialability Observability

Table 11 Summary of Theories Focus and Key Concepts

Individual Level

Interpersonal Level

Community Level

Theory Focus

Health Belief Model Individualsrsquo perceptions of the threat posed by a health problem the benefits of avoiding the threat and factors influencing the decision to act

45

PART 3

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

Precaution Adoption Process Model

Social Cognitive Theory

Community Organization

Communication Theory

Individualsrsquo journey from lack of awareness to action and maintenance

Personal factors environmental factors and human behavior exert influence on each other

Community-driven approaches to assessing and solving health and social problems

How different types of communication affect health behavior

Key Concepts

Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Cues to action Self-efficacy

Unaware of issue Unengaged by issue Deciding about acting Deciding not to act Deciding to act Acting Maintenance

Reciprocal determinism Behavioral capability Expectations Self-efficacy Observational learning Reinforcements

Empowerment Community capacity Participation Relevance Issue selection Critical consciousness

Example Agenda Setting Media agenda setting Public agenda setting Policy agenda setting Problem identification

definition Framing

Figure 10 Using Theory to Plan Multilevel Interventions

Change Strategies

Change Peoplersquos Behavior

Change the Environment

bull bull bull bull

Examples of Strategies

Educational sessions Interactive kiosks Print brochures Social marketing campaigns

Ecological Level

Individual

Useful Theories

Stages of Change Precaution Adoption Process Health Belief Model Theory of Planned Behavior

bull bull

Mentoring programs Lay health advising

Interpersonal Social Cognitive Theory

bull

bull

Media advocacy campaigns Advocating changes to company policy

Community Communication Theory Diffusion of Innovations Community Organizing

47

PART 3

46

T H E O

R Y

AT

A G

L A N

C E

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

behavior change theories and planning systems practitioners gain access to tools that allow them to generate creative solutions to unique situations They are able to go beyond acting on instinct or repeating earlier interventions to adopt a systematic scientific approach to their work Theory helps practitioners to ask the right questions and effective planning helps them zero in on factors that contribute to a problem Other key elements of effective programs include matching programs to the audience making information accessible and practical involving participants in active learning and including elements that build skills and reinforce behavior change

Becoming comfortable with behavior change theory as an instrument of practice may take some work but the results are well worth it Behavior change theory is not simply a tool for academics and researchers it can be applied to the problems health promotion practitioners face every day The abstractions of theory help practitioners to understand the dynamics underlying real situations and to think about solutions in a new way Armed with this resource you may find yourself saying as did Winston Churchill in 1898 ldquoI pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Factrdquo

48

T H E O

R Y

AT

A G

L A N

C E

Sources

Bandura A Social Foundations of Thought and Action A Social Cognitive Theory Englewood Cliffs NJ Prentice-Hall 1986

Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

Prochaska JO DiClemente CC Norcross JC In Search of How People Change Applications to the Addictive Behaviors American Psychologist 471102ndash1114 1992

Rosenstock IM Strecher VJ Becker MH Social Learning Theory and the Health Belief Model Health Education Quarterly 15(2)175ndash183 1988

van Ryn M Heaney CA Developing Effective Helping Relationships in Health Education Practice Health Education and Behavior 24683ndash702 1997

Kotler P Andreasen A Strategic Marketing for Nonprofit Organizations (5th Edition) Prentice-Hall 1996

Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

Glanz Karen and Rimer Barbara K Theory at a Glance A Guide for Health Promotion Practice National Cancer Institute National Institutes of Health US Department of Health and Human Services NIH Pub No 97-3896 Washington DC NIH Revised September 1997

References

1 Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

2 Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

3 Kreuter MW Skinner CS Tailoring whatrsquos in a name Health Education Research 15(1)1 2000

4 McLeroy KR Bibeau D Steckler A Glanz K An ecological perspective on health promotion programs Health Education Quarterly 15351ndash377 1988

5 Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention US Department of Health and Human Services Best Practices for Comprehensive Tobacco Control Programs Atlanta Ga August 1999

6 Prochaska JO DiClemente CC Stages and processes of self-change of smoking Toward an integrative model of change Journal of Consulting and Clinical Psychology 51(3) 390ndash395 1983

7 Azjen I Driver BL Prediction of leisure participation from behavioral normative and control beliefs an application of the theory of planned behavior Leisure Science 13185ndash204 1991

8 Mandelblatt JS Gold K OrsquoMalley AS et al Breast and cervix cancer screening among multiethnic women Role of age health and source of care Preventive Medicine 28418ndash425 1999

9 Institute of Medicine op cit

10 Baranowski T et al Increasing fruit and vegetable consumption among 4th and 5th grade students results from focus groups using reciprocal determinism Journal of Nutrition Education 25114ndash327 1993

11 Lorig K Sobel D Stewart A et al Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization Medical Care 37(1)5ndash14 1999

12 Fetterman DM Kaftarian SJ Wandersman A Empowerment Evaluation Knowledge and Tools for Self-assessment and Accountability Thousand Oaks Calif Sage Publications 1996

13 Fawcett SB Francisco VT Schultz JA et al The Community Tool Box A Web-Based Resource for Building Healthier Communities Public Health Rep 115(2-3)274ndash8 Mar-Jun 2000

49

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

Planning Step Function Examples of Relevant Theory

1 Social Assessment Assesses peoplersquos views of their own needs and quality of life

Community organization

Community building

2 Epidemiological Assessment

Documents which health problems are most important for which groups in a community

Community-level theories (If the community helps to choose the health problem that will be addressed)

3 Behavioral Environmental

Assessment

Identifies factors that contribute to the health problem of interest

Interpersonal theories - Social Cognitive Theory

Theories of organizational change

Community organization

Diffusion of innovations

4 Educational Ecological

Assessment

Identifies preceding and reinforcing factors that must be in place to initiate and sustain change

All three levels of change theories - Individual - Interpersonal - Community

5 Administrative Policy

Assessment

Identifies policies resources and circumstances in the programrsquos context that may help or hinder implementation

Community-level theories - Community organization - Organizational change

organization relates to Step 1 which may entail working with communities to identify their own needs strengths resources and capacities Descriptive epidemiology is most pertinent to Step 2 but community-level theories may be relevant if the community helps to choose the health problem that will be addressed or to set priorities among health problems Theory is most directly useful when applied to steps 3 4 and 5 since these steps call upon the practitioner to make strategic decisions By using theory the practitioner can make sound choices that are based upon more than just intuition and personal judgment

Theory should guide practitionersrsquo examshyination of predisposing enabling and reinforcing factors For example the Health Belief Model suggests that certain beliefs might influence womenrsquos decisions about whether or not to get a mammogram such as perceived chances of developing cancer (perceived susceptibility) or how serious they believe cancer would be (perceived severity) Both beliefs constitute predisposing factors Other HBM constructs may identify possible perceived benefits of and barriers to screening Receiving

reassurance that they do not have cancer (perceived benefit) might be a reinforcing factor Lack of insurance coverage for screening mammography (perceived barrier) could be a negative enabling factor

By exploring the degree to which each of these factors affects womenrsquos behaviors program planners can decide how to focus program messages for a communications campaign or strategies for an administrative intervention (such as providing low- or no-cost screening or changing insurance coverage) The best way to verify and rank explanations offered by theory is to gather information directly from women in the target population Another less ideal

To make appropriate use of theory in a given situation practitioners must consider both the social or health problem at hand and the context in which the intervention will take place Once they have identified a problem they can use a planning system such as social marketing or PRECEDEshyPROCEED to identify social science theories that contribute to their understanding These theories can guide them to potential points of intervention Consulting the research literature helps practitioners to learn about the past successes or failures of intervention strategies that they consider and reflect on whether those strategies are likely to work for the current situation Pre-testing

43

PART 3

42

T H E O

R Y

AT

A G

L A N

C E

Table 10 Diagnostic Elements of PRECEDE-PROCEED approach is to learn by reading research and actively discussing proposed literature on women who share strategies with the target audience can characteristics with the target population also help to determine whether or not they

will be well received

P U

T T I N G

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Where to Begin Choosing the Right Theories

Interventions that evolve from a comprehensive planning process build on prior research and use health behavior theories are more likely to be effective By investigating what factors influence the target populationrsquos behavior including their social and physical environments practitioners gain the raw materials they need to meet the needs of that population Theory helps practitioners to interpret the findings of their research making the leap from facts on a page to understanding the dynamic interactions between behavior and environmental context Systematic approaches to tailoring targeting implementing and evaluating programs provide practitioners with a framework for translating this insight into actions that improve health outcomes

Table 11 summarizes the focus and key concepts of each of the eight theories described in this guide Refer to this table to identify theories that help explain and address a health problem For example several theories could be used to inform the design of a program to reduce tobacco use among adolescents By scanning the ldquoFocusrdquo column one can quickly gauge which theories might apply to a particular situation For example The Stages of Change model might be very useful since it centers on individualsrsquo readiness to change On the other hand the Health Belief Model seems less promising since young people may be less concerned about long-term health problems (In fact they may not feel vulnerable to disease at all) Social Cognitive Theory could be helpful because it emphasizes the interplay between personal environmental and behavior factors Likewise Community Organization could offer perspective on activating young people

around tobacco control issues Applying step-by-step process of examining health each of these theories might look like this and behavior at multiple levels

44

T H E O

R Y

AT

A G

L A N

C E

bull Stages of Change Learn more about readiness to change among adolescents who smoke in order to plan appropriate and effective cessation messages and strategies

bull Social Cognitive Theory Examine how social environment including peer attitudes influences adolescentsrsquo tobacco use What are the expectations of teens who experiment with tobacco or who use it regularly How do observational learning and reinforcement contribute to the reasons why they smoke Might these constructs help identify someone who can successfully help them to quit

bull Community Organization Consider how to involve teen smokers in developing and carrying out the program One idea might be to organize a coalition of concerned parents teachers and teens to help explore why teens smoke and identify potential solutions

The examples above offer a basic illustration of how multiple theories might be combined to address a single problem The resulting program would be a multishyfaceted multilevel effort

A Few Final Words

Once one is familiar with some contemporary theories of health behavior the challenge is to use them appropriately within a comprehensive planning process Planning systems such as social marketing and PRECEDE-PROCEED facilitate the process of developing successful programs because they lead practitioners through a

At the most basic level an ecological perspective points to two approaches to addressing health problems change peoplersquos behavior or change the environment The most powerful health promotion and behavior change interventions integrate these approaches and treat them both as essential Figure 10 illustrates that strategies intended to change peoplersquos behavior can often be derived from individual-level theories those aimed at changing the environment draw on community-level theories Theories at the interpersonal level (such as Social Cognitive Theory) lie in-between exploring the reciprocal exchanges between individuals and their environments

Practitioners who are aware of reciprocal causation (ie that individual behavior both influences and is influenced by the environment) are more likely to design multidimensional effective health promotion programs A change strategy based on individual-level theory may indirectly lead to changes in the environment (eg when individualsrsquo improved eating habits drive the cafeteria to offer healthier choices) By the same token a strategy based on community-level theory may yield improved individual health behaviors (eg when an individualrsquos involvement in a community organizing project to improve access to fruits and vegetables in the community inspires her to cook healthier foods for her family)

Theoretical frameworks offer flexible guidance for applying the abstract concepts of theory to a vast array of real circumstances By becoming familiar with

Stages of Change Model

Theory of Planned Behavior

Diffusion of Innovations

Individualsrsquo motivation and readiness to change a problem behavior

Individualsrsquo attitudes toward a behavior perceptions of norms and beliefs about the ease or difficulty of changing

How new ideas products and practices spread within a society or from one society to another

Precontemplation Contemplation Decision Action Maintenance

Behavioral intention Attitude Subjective norm Perceived behavioral control

Relative advantage Compatibility Complexity Trialability Observability

Table 11 Summary of Theories Focus and Key Concepts

Individual Level

Interpersonal Level

Community Level

Theory Focus

Health Belief Model Individualsrsquo perceptions of the threat posed by a health problem the benefits of avoiding the threat and factors influencing the decision to act

45

PART 3

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

Precaution Adoption Process Model

Social Cognitive Theory

Community Organization

Communication Theory

Individualsrsquo journey from lack of awareness to action and maintenance

Personal factors environmental factors and human behavior exert influence on each other

Community-driven approaches to assessing and solving health and social problems

How different types of communication affect health behavior

Key Concepts

Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Cues to action Self-efficacy

Unaware of issue Unengaged by issue Deciding about acting Deciding not to act Deciding to act Acting Maintenance

Reciprocal determinism Behavioral capability Expectations Self-efficacy Observational learning Reinforcements

Empowerment Community capacity Participation Relevance Issue selection Critical consciousness

Example Agenda Setting Media agenda setting Public agenda setting Policy agenda setting Problem identification

definition Framing

Figure 10 Using Theory to Plan Multilevel Interventions

Change Strategies

Change Peoplersquos Behavior

Change the Environment

bull bull bull bull

Examples of Strategies

Educational sessions Interactive kiosks Print brochures Social marketing campaigns

Ecological Level

Individual

Useful Theories

Stages of Change Precaution Adoption Process Health Belief Model Theory of Planned Behavior

bull bull

Mentoring programs Lay health advising

Interpersonal Social Cognitive Theory

bull

bull

Media advocacy campaigns Advocating changes to company policy

Community Communication Theory Diffusion of Innovations Community Organizing

47

PART 3

46

T H E O

R Y

AT

A G

L A N

C E

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

behavior change theories and planning systems practitioners gain access to tools that allow them to generate creative solutions to unique situations They are able to go beyond acting on instinct or repeating earlier interventions to adopt a systematic scientific approach to their work Theory helps practitioners to ask the right questions and effective planning helps them zero in on factors that contribute to a problem Other key elements of effective programs include matching programs to the audience making information accessible and practical involving participants in active learning and including elements that build skills and reinforce behavior change

Becoming comfortable with behavior change theory as an instrument of practice may take some work but the results are well worth it Behavior change theory is not simply a tool for academics and researchers it can be applied to the problems health promotion practitioners face every day The abstractions of theory help practitioners to understand the dynamics underlying real situations and to think about solutions in a new way Armed with this resource you may find yourself saying as did Winston Churchill in 1898 ldquoI pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Factrdquo

48

T H E O

R Y

AT

A G

L A N

C E

Sources

Bandura A Social Foundations of Thought and Action A Social Cognitive Theory Englewood Cliffs NJ Prentice-Hall 1986

Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

Prochaska JO DiClemente CC Norcross JC In Search of How People Change Applications to the Addictive Behaviors American Psychologist 471102ndash1114 1992

Rosenstock IM Strecher VJ Becker MH Social Learning Theory and the Health Belief Model Health Education Quarterly 15(2)175ndash183 1988

van Ryn M Heaney CA Developing Effective Helping Relationships in Health Education Practice Health Education and Behavior 24683ndash702 1997

Kotler P Andreasen A Strategic Marketing for Nonprofit Organizations (5th Edition) Prentice-Hall 1996

Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

Glanz Karen and Rimer Barbara K Theory at a Glance A Guide for Health Promotion Practice National Cancer Institute National Institutes of Health US Department of Health and Human Services NIH Pub No 97-3896 Washington DC NIH Revised September 1997

References

1 Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

2 Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

3 Kreuter MW Skinner CS Tailoring whatrsquos in a name Health Education Research 15(1)1 2000

4 McLeroy KR Bibeau D Steckler A Glanz K An ecological perspective on health promotion programs Health Education Quarterly 15351ndash377 1988

5 Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention US Department of Health and Human Services Best Practices for Comprehensive Tobacco Control Programs Atlanta Ga August 1999

6 Prochaska JO DiClemente CC Stages and processes of self-change of smoking Toward an integrative model of change Journal of Consulting and Clinical Psychology 51(3) 390ndash395 1983

7 Azjen I Driver BL Prediction of leisure participation from behavioral normative and control beliefs an application of the theory of planned behavior Leisure Science 13185ndash204 1991

8 Mandelblatt JS Gold K OrsquoMalley AS et al Breast and cervix cancer screening among multiethnic women Role of age health and source of care Preventive Medicine 28418ndash425 1999

9 Institute of Medicine op cit

10 Baranowski T et al Increasing fruit and vegetable consumption among 4th and 5th grade students results from focus groups using reciprocal determinism Journal of Nutrition Education 25114ndash327 1993

11 Lorig K Sobel D Stewart A et al Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization Medical Care 37(1)5ndash14 1999

12 Fetterman DM Kaftarian SJ Wandersman A Empowerment Evaluation Knowledge and Tools for Self-assessment and Accountability Thousand Oaks Calif Sage Publications 1996

13 Fawcett SB Francisco VT Schultz JA et al The Community Tool Box A Web-Based Resource for Building Healthier Communities Public Health Rep 115(2-3)274ndash8 Mar-Jun 2000

49

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

around tobacco control issues Applying step-by-step process of examining health each of these theories might look like this and behavior at multiple levels

44

T H E O

R Y

AT

A G

L A N

C E

bull Stages of Change Learn more about readiness to change among adolescents who smoke in order to plan appropriate and effective cessation messages and strategies

bull Social Cognitive Theory Examine how social environment including peer attitudes influences adolescentsrsquo tobacco use What are the expectations of teens who experiment with tobacco or who use it regularly How do observational learning and reinforcement contribute to the reasons why they smoke Might these constructs help identify someone who can successfully help them to quit

bull Community Organization Consider how to involve teen smokers in developing and carrying out the program One idea might be to organize a coalition of concerned parents teachers and teens to help explore why teens smoke and identify potential solutions

The examples above offer a basic illustration of how multiple theories might be combined to address a single problem The resulting program would be a multishyfaceted multilevel effort

A Few Final Words

Once one is familiar with some contemporary theories of health behavior the challenge is to use them appropriately within a comprehensive planning process Planning systems such as social marketing and PRECEDE-PROCEED facilitate the process of developing successful programs because they lead practitioners through a

At the most basic level an ecological perspective points to two approaches to addressing health problems change peoplersquos behavior or change the environment The most powerful health promotion and behavior change interventions integrate these approaches and treat them both as essential Figure 10 illustrates that strategies intended to change peoplersquos behavior can often be derived from individual-level theories those aimed at changing the environment draw on community-level theories Theories at the interpersonal level (such as Social Cognitive Theory) lie in-between exploring the reciprocal exchanges between individuals and their environments

Practitioners who are aware of reciprocal causation (ie that individual behavior both influences and is influenced by the environment) are more likely to design multidimensional effective health promotion programs A change strategy based on individual-level theory may indirectly lead to changes in the environment (eg when individualsrsquo improved eating habits drive the cafeteria to offer healthier choices) By the same token a strategy based on community-level theory may yield improved individual health behaviors (eg when an individualrsquos involvement in a community organizing project to improve access to fruits and vegetables in the community inspires her to cook healthier foods for her family)

Theoretical frameworks offer flexible guidance for applying the abstract concepts of theory to a vast array of real circumstances By becoming familiar with

Stages of Change Model

Theory of Planned Behavior

Diffusion of Innovations

Individualsrsquo motivation and readiness to change a problem behavior

Individualsrsquo attitudes toward a behavior perceptions of norms and beliefs about the ease or difficulty of changing

How new ideas products and practices spread within a society or from one society to another

Precontemplation Contemplation Decision Action Maintenance

Behavioral intention Attitude Subjective norm Perceived behavioral control

Relative advantage Compatibility Complexity Trialability Observability

Table 11 Summary of Theories Focus and Key Concepts

Individual Level

Interpersonal Level

Community Level

Theory Focus

Health Belief Model Individualsrsquo perceptions of the threat posed by a health problem the benefits of avoiding the threat and factors influencing the decision to act

45

PART 3

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

Precaution Adoption Process Model

Social Cognitive Theory

Community Organization

Communication Theory

Individualsrsquo journey from lack of awareness to action and maintenance

Personal factors environmental factors and human behavior exert influence on each other

Community-driven approaches to assessing and solving health and social problems

How different types of communication affect health behavior

Key Concepts

Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Cues to action Self-efficacy

Unaware of issue Unengaged by issue Deciding about acting Deciding not to act Deciding to act Acting Maintenance

Reciprocal determinism Behavioral capability Expectations Self-efficacy Observational learning Reinforcements

Empowerment Community capacity Participation Relevance Issue selection Critical consciousness

Example Agenda Setting Media agenda setting Public agenda setting Policy agenda setting Problem identification

definition Framing

Figure 10 Using Theory to Plan Multilevel Interventions

Change Strategies

Change Peoplersquos Behavior

Change the Environment

bull bull bull bull

Examples of Strategies

Educational sessions Interactive kiosks Print brochures Social marketing campaigns

Ecological Level

Individual

Useful Theories

Stages of Change Precaution Adoption Process Health Belief Model Theory of Planned Behavior

bull bull

Mentoring programs Lay health advising

Interpersonal Social Cognitive Theory

bull

bull

Media advocacy campaigns Advocating changes to company policy

Community Communication Theory Diffusion of Innovations Community Organizing

47

PART 3

46

T H E O

R Y

AT

A G

L A N

C E

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

behavior change theories and planning systems practitioners gain access to tools that allow them to generate creative solutions to unique situations They are able to go beyond acting on instinct or repeating earlier interventions to adopt a systematic scientific approach to their work Theory helps practitioners to ask the right questions and effective planning helps them zero in on factors that contribute to a problem Other key elements of effective programs include matching programs to the audience making information accessible and practical involving participants in active learning and including elements that build skills and reinforce behavior change

Becoming comfortable with behavior change theory as an instrument of practice may take some work but the results are well worth it Behavior change theory is not simply a tool for academics and researchers it can be applied to the problems health promotion practitioners face every day The abstractions of theory help practitioners to understand the dynamics underlying real situations and to think about solutions in a new way Armed with this resource you may find yourself saying as did Winston Churchill in 1898 ldquoI pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Factrdquo

48

T H E O

R Y

AT

A G

L A N

C E

Sources

Bandura A Social Foundations of Thought and Action A Social Cognitive Theory Englewood Cliffs NJ Prentice-Hall 1986

Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

Prochaska JO DiClemente CC Norcross JC In Search of How People Change Applications to the Addictive Behaviors American Psychologist 471102ndash1114 1992

Rosenstock IM Strecher VJ Becker MH Social Learning Theory and the Health Belief Model Health Education Quarterly 15(2)175ndash183 1988

van Ryn M Heaney CA Developing Effective Helping Relationships in Health Education Practice Health Education and Behavior 24683ndash702 1997

Kotler P Andreasen A Strategic Marketing for Nonprofit Organizations (5th Edition) Prentice-Hall 1996

Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

Glanz Karen and Rimer Barbara K Theory at a Glance A Guide for Health Promotion Practice National Cancer Institute National Institutes of Health US Department of Health and Human Services NIH Pub No 97-3896 Washington DC NIH Revised September 1997

References

1 Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

2 Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

3 Kreuter MW Skinner CS Tailoring whatrsquos in a name Health Education Research 15(1)1 2000

4 McLeroy KR Bibeau D Steckler A Glanz K An ecological perspective on health promotion programs Health Education Quarterly 15351ndash377 1988

5 Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention US Department of Health and Human Services Best Practices for Comprehensive Tobacco Control Programs Atlanta Ga August 1999

6 Prochaska JO DiClemente CC Stages and processes of self-change of smoking Toward an integrative model of change Journal of Consulting and Clinical Psychology 51(3) 390ndash395 1983

7 Azjen I Driver BL Prediction of leisure participation from behavioral normative and control beliefs an application of the theory of planned behavior Leisure Science 13185ndash204 1991

8 Mandelblatt JS Gold K OrsquoMalley AS et al Breast and cervix cancer screening among multiethnic women Role of age health and source of care Preventive Medicine 28418ndash425 1999

9 Institute of Medicine op cit

10 Baranowski T et al Increasing fruit and vegetable consumption among 4th and 5th grade students results from focus groups using reciprocal determinism Journal of Nutrition Education 25114ndash327 1993

11 Lorig K Sobel D Stewart A et al Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization Medical Care 37(1)5ndash14 1999

12 Fetterman DM Kaftarian SJ Wandersman A Empowerment Evaluation Knowledge and Tools for Self-assessment and Accountability Thousand Oaks Calif Sage Publications 1996

13 Fawcett SB Francisco VT Schultz JA et al The Community Tool Box A Web-Based Resource for Building Healthier Communities Public Health Rep 115(2-3)274ndash8 Mar-Jun 2000

49

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

Figure 10 Using Theory to Plan Multilevel Interventions

Change Strategies

Change Peoplersquos Behavior

Change the Environment

bull bull bull bull

Examples of Strategies

Educational sessions Interactive kiosks Print brochures Social marketing campaigns

Ecological Level

Individual

Useful Theories

Stages of Change Precaution Adoption Process Health Belief Model Theory of Planned Behavior

bull bull

Mentoring programs Lay health advising

Interpersonal Social Cognitive Theory

bull

bull

Media advocacy campaigns Advocating changes to company policy

Community Communication Theory Diffusion of Innovations Community Organizing

47

PART 3

46

T H E O

R Y

AT

A G

L A N

C E

P U

T T I N G

T H E O

R Y A

N D

P R

A C

T I C E T O

G E T H

E R

behavior change theories and planning systems practitioners gain access to tools that allow them to generate creative solutions to unique situations They are able to go beyond acting on instinct or repeating earlier interventions to adopt a systematic scientific approach to their work Theory helps practitioners to ask the right questions and effective planning helps them zero in on factors that contribute to a problem Other key elements of effective programs include matching programs to the audience making information accessible and practical involving participants in active learning and including elements that build skills and reinforce behavior change

Becoming comfortable with behavior change theory as an instrument of practice may take some work but the results are well worth it Behavior change theory is not simply a tool for academics and researchers it can be applied to the problems health promotion practitioners face every day The abstractions of theory help practitioners to understand the dynamics underlying real situations and to think about solutions in a new way Armed with this resource you may find yourself saying as did Winston Churchill in 1898 ldquoI pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Factrdquo

48

T H E O

R Y

AT

A G

L A N

C E

Sources

Bandura A Social Foundations of Thought and Action A Social Cognitive Theory Englewood Cliffs NJ Prentice-Hall 1986

Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

Prochaska JO DiClemente CC Norcross JC In Search of How People Change Applications to the Addictive Behaviors American Psychologist 471102ndash1114 1992

Rosenstock IM Strecher VJ Becker MH Social Learning Theory and the Health Belief Model Health Education Quarterly 15(2)175ndash183 1988

van Ryn M Heaney CA Developing Effective Helping Relationships in Health Education Practice Health Education and Behavior 24683ndash702 1997

Kotler P Andreasen A Strategic Marketing for Nonprofit Organizations (5th Edition) Prentice-Hall 1996

Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

Glanz Karen and Rimer Barbara K Theory at a Glance A Guide for Health Promotion Practice National Cancer Institute National Institutes of Health US Department of Health and Human Services NIH Pub No 97-3896 Washington DC NIH Revised September 1997

References

1 Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

2 Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

3 Kreuter MW Skinner CS Tailoring whatrsquos in a name Health Education Research 15(1)1 2000

4 McLeroy KR Bibeau D Steckler A Glanz K An ecological perspective on health promotion programs Health Education Quarterly 15351ndash377 1988

5 Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention US Department of Health and Human Services Best Practices for Comprehensive Tobacco Control Programs Atlanta Ga August 1999

6 Prochaska JO DiClemente CC Stages and processes of self-change of smoking Toward an integrative model of change Journal of Consulting and Clinical Psychology 51(3) 390ndash395 1983

7 Azjen I Driver BL Prediction of leisure participation from behavioral normative and control beliefs an application of the theory of planned behavior Leisure Science 13185ndash204 1991

8 Mandelblatt JS Gold K OrsquoMalley AS et al Breast and cervix cancer screening among multiethnic women Role of age health and source of care Preventive Medicine 28418ndash425 1999

9 Institute of Medicine op cit

10 Baranowski T et al Increasing fruit and vegetable consumption among 4th and 5th grade students results from focus groups using reciprocal determinism Journal of Nutrition Education 25114ndash327 1993

11 Lorig K Sobel D Stewart A et al Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization Medical Care 37(1)5ndash14 1999

12 Fetterman DM Kaftarian SJ Wandersman A Empowerment Evaluation Knowledge and Tools for Self-assessment and Accountability Thousand Oaks Calif Sage Publications 1996

13 Fawcett SB Francisco VT Schultz JA et al The Community Tool Box A Web-Based Resource for Building Healthier Communities Public Health Rep 115(2-3)274ndash8 Mar-Jun 2000

49

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

48

T H E O

R Y

AT

A G

L A N

C E

Sources

Bandura A Social Foundations of Thought and Action A Social Cognitive Theory Englewood Cliffs NJ Prentice-Hall 1986

Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

Prochaska JO DiClemente CC Norcross JC In Search of How People Change Applications to the Addictive Behaviors American Psychologist 471102ndash1114 1992

Rosenstock IM Strecher VJ Becker MH Social Learning Theory and the Health Belief Model Health Education Quarterly 15(2)175ndash183 1988

van Ryn M Heaney CA Developing Effective Helping Relationships in Health Education Practice Health Education and Behavior 24683ndash702 1997

Kotler P Andreasen A Strategic Marketing for Nonprofit Organizations (5th Edition) Prentice-Hall 1996

Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

Glanz Karen and Rimer Barbara K Theory at a Glance A Guide for Health Promotion Practice National Cancer Institute National Institutes of Health US Department of Health and Human Services NIH Pub No 97-3896 Washington DC NIH Revised September 1997

References

1 Glanz K Rimer BK Lewis FM Health Behavior and Health Education Theory Research and Practice (3rd Edition) San Francisco Calif Jossey-Bass 2002

2 Institute of Medicine Speaking of Health Assessing Health Communications Strategies for Diverse Populations Washington DC National Academies Press 2002

3 Kreuter MW Skinner CS Tailoring whatrsquos in a name Health Education Research 15(1)1 2000

4 McLeroy KR Bibeau D Steckler A Glanz K An ecological perspective on health promotion programs Health Education Quarterly 15351ndash377 1988

5 Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention US Department of Health and Human Services Best Practices for Comprehensive Tobacco Control Programs Atlanta Ga August 1999

6 Prochaska JO DiClemente CC Stages and processes of self-change of smoking Toward an integrative model of change Journal of Consulting and Clinical Psychology 51(3) 390ndash395 1983

7 Azjen I Driver BL Prediction of leisure participation from behavioral normative and control beliefs an application of the theory of planned behavior Leisure Science 13185ndash204 1991

8 Mandelblatt JS Gold K OrsquoMalley AS et al Breast and cervix cancer screening among multiethnic women Role of age health and source of care Preventive Medicine 28418ndash425 1999

9 Institute of Medicine op cit

10 Baranowski T et al Increasing fruit and vegetable consumption among 4th and 5th grade students results from focus groups using reciprocal determinism Journal of Nutrition Education 25114ndash327 1993

11 Lorig K Sobel D Stewart A et al Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization Medical Care 37(1)5ndash14 1999

12 Fetterman DM Kaftarian SJ Wandersman A Empowerment Evaluation Knowledge and Tools for Self-assessment and Accountability Thousand Oaks Calif Sage Publications 1996

13 Fawcett SB Francisco VT Schultz JA et al The Community Tool Box A Web-Based Resource for Building Healthier Communities Public Health Rep 115(2-3)274ndash8 Mar-Jun 2000

49

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

50

T H E O

R Y

AT

A G

L A N

C E

14 Rothman J Approaches to Community Intervention In Rothman J Erlich JL Tropman JE (eds) Strategies of Community Intervention Itasca Ill Peacock Publishers 2001

15 Wallerstein N Powerlessness empowerment and health implications for health promotion programs American Journal of Health Promotion 6197ndash205 1992

16 Fisher R Social Action Community Organization Proliferation Persistence Roots and Prospects In Minkler M (ed) Community Organizing and Community Building for Health Rutgers NJ Rutgers University Press 1997

17 Alinsky SD Rules for Radicals New York NY Vintage Books 1989

18 Parachini L Covington S Community Organizing Toolbox A Funderrsquos Guide to Community Organizing Neighborhood Funders Group Washington DC April 2001 URL httpwwwaecforgtarcpublicationspubs_toolboxphp

19 Alinsky op cit

20 Dorfman L Wallack L Themba M Media Advocacy and Public Health Power for Prevention Newbury Park Calif Sage Publications 1993

21 Wallack L Dorfman L Issue 1 Berkeley Media Studies Group Berkeley CA January 1997

22 Nichter M Project community diagnosis Participatory research as a first step toward community involvement in primary health care in Hahn RA (ed) Anthropology in public health Bridging the differences in culture and society New York NY Oxford University Press 1999

23 Thompson B Nettekoven L Ferster D Stanley LC Thompson J Corbett KK Chapter 5 Mobilizing the COMMIT Communities for Smoking Control Smoking and Tobacco Control Monograph 6 Community-Based Interventions for Smokers The COMMIT Field Experience Tobacco Control Research Branch Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health 1993

24 Community-based interventions for smokers The COMMIT Field Experience Smoking and Tobacco Control Monograph No 6 Burns D Garfinkel L Samet J editors USDHHS NIH NCI NIH Publication No 95-4028 1995

25 Institute of Medicine op cit

26 National Cancer Policy Board Institute of Medicine Fulfilling the Potential of Cancer Prevention and Early Detection Washington DC The National Academies Press 2003

27 Rogers EM Diffusion of Innovations (4th Edition) New York NY Free Press 1995

28 Bernhardt JM Communication at the Core of Public Health American Journal of Public Health 94(12) 2051ndash2052 December 2004

29 Ibid

30 Office of Cancer Communications National Cancer Institute Making Health Communication Programs Work A Plannerrsquos Guide (revised December 2001) NIH Pub No 02-5145 2002

31 Freimuth V Quinn SC The Contributions of Health Communication to Eliminating Health Disparities American Journal of Public Health 94(12)2053ndash2054 December 2004

32 Institute of Medicine op cit

33 Freimuth V Quinn SC op cit

34 Ibid

35 Ibid

36 Dorfman L Wallack L Themba M op cit

37 Eysenbach G What is e-health Journal of Medical Internet Research 3(2)e20 2001 URL httpwwwjmirorg20012e20

38 Eng TR The eHealth Landscape A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care The Robert Woods Johnson Foundation 2001 URL httpwwwinformatics-reviewcomthoughtsrwjfhtml

39 Neuhauser L Kreps G Rethinking Communication in the E-health Era Journal of Health Psychology 8(1) 7ndash22 2003

40 Science Panel on Interactive Communication and Health Wired for Health and Well-Being The Emergence of Interactive Health Communications US Department of Health and Human Services US Government Printing Office Washington DC April 1999 URL httpwwwhealthgovscipichpubsfinalreporthtm

41 Cassell MM Jackson C Cheuvront B Health communication on the Internet an effective channel for health behavior change J Health Commun 3(1)71-9 Jan-Mar 1998

42 Institute of Medicine op cit

43 Lieberman DA Interactive video games for health promotion Effects on knowledge self-efficacy social support and health RL Street WR Gold amp T Manning (Eds) Health promotion and interactive technology Theoretical applications and future directions Mahwah NJ Lawrence Erlbaum Associates pp 103ndash120 1997

44 Lieberman DA Management of chronic pediatric diseases with interactive health games Theory and research findings Journal of Ambulatory Care Management 24(1)26ndash38 2001

51

T H E O

R Y A

T A G

L A N

C E

52

T H E O

R Y

AT

A G

L A N

C E

45 Kreps GL Evaluating new health information technologies expanding the frontiers of health care delivery and health promotion Stud Health Technol Inform 80205ndash12 2002

46 US Department of Commerce A Nation On-line How Americans are Expanding their Use of the Internet Economics and Statistics Administration National Telecommunications and Information Administration February 2002 URL httpwwwntiadocgovntiahomednanationonline2pdf

47 Leslie Harris amp Associates Bringing a Nation On-line The Importance of Federal Leadership The Leadership Conference on Civil Rights Education Fund and the Benton Foundation July 2002 URL httpwwwbentonorgpublibrarynationonlinebringing_a_nationpdf

48 Institute of Medicine op cit

49 Andreasen A Marketing Social Change Changing Behavior to Promote Health Social Development and the Environment San Francisco Calif Jossey-Bass 1995

50 National Cancer Institute 5 A Day for Better Health Program Chapter 1 National Institutes of Health NIH Pub No 01-5019 Washington DC September 2001

51 California Department of Health Services Cancer Prevention and Nutrition Section Eat 5 A Day for Better Health 2005 URL httpwwwdhscagovpscdiccpnsca5aday

52 Alcalay R Bell R Promoting Nutrition and Physical Activity Through Social Marketing Department of Communication and the Center for Advanced Studies in Nutrition and Social Marketing University of California Davis June 2000 httpsocialmarketing-nutritionucdavisedupublicationshtm

53 Green LW Kreuter MW Health Promotion Planning An Educational and Ecological Approach (3rd edition) McGraw-Hill 1999